Efficacy and safety of intraoperative injection of mitomycin C during trabeculectomy: a systematic review and meta-analysis.

PURPOSE: Trabeculectomy, a primary surgical treatment for glaucoma, often employs mitomycin C (MMC) to reduce scar formation and improve surgical outcomes. However, the optimal application method of MMC, whether by injection or sponge, remains a subject of debate. This meta-analysis aims to compare injectable and sponge-based MMC application in terms of efficacy and safety, focusing on various clinical outcomes in glaucoma patients. METHODS: A comprehensive literature search of Scopus, MEDLINE, EMBASE, Ovid, Chinese biomedical literature database, China National Knowledge Infrastructure, and Cochrane Library was done for eligible studies that report data of glaucoma patients who were administered MMC by injection or sponge application during trabeculectomy. Outcomes of interest included intraocular pressure (IOP) reduction, bleb appearance grading (height, extent, vascularity), use of anti-glaucoma medications, and rates of complete success, qualified success, and failure. Data were reported as weighted mean differences (WMD) or odds ratios (OR) with confidence intervals (CI). The random-effects inverse-variance model with DerSimonian-Laird estimate of tau2 was employed, with continuity correction applied where necessary. RESULTS: A total of 15 studies with 1276 participants were included. The meta-analysis revealed no significant difference in IOP reduction between patients treated by MMC injection and sponge application (WMD = - 0.434). Significant differences were observed in bleb appearance grading scores for height (WMD = - 0.170) and extent (WMD = 0.174), with substantial heterogeneity. The use of anti-glaucoma medications was significantly lower in the injection group (WMD = - 0.274). However, there were no significant differences in the rates of complete success, qualified success, and failure. The study demonstrated moderate to high heterogeneity across various outcomes. CONCLUSION: This meta-analysis indicated that while both injection and sponge methods of MMC application during trabeculectomy were equally effective for IOP reduction, they differ in their impact on bleb morphology and postoperative medication requirement. The findings highlight the need for individualized treatment approaches in glaucoma surgery, taking into account the specific needs and characteristics of each patient.

Qualitative exploration of patients' experiences with Intrabeam TARGeted Intraoperative radioTherapy (TARGIT-IORT) and External-Beam RadioTherapy Treatment (EBRT) for breast cancer.

OBJECTIVE: To gather a deep qualitative understanding of the perceived benefits and impacts of External-Beam RadioTherapy (EBRT) and TARGeted Intraoperative radioTherapy (TARGIT-IORT) using Intrabeam to assess how the treatments affected patient/care partner experiences during their cancer treatment and beyond. DESIGN AND PARTICIPANTS: A patient-led working group was established to guide study design and to help validate findings. Patients with experience of receiving EBRT or TARGIT-IORT were purposively sampled by Hampshire Hospitals NHS Foundation Trust. These patients had been offered both regimens as per their clinical features and eligibility. Semistructured interviews were conducted with 29 patients and care partners with lived experience of either EBRT (n=12, 5-day FAST-Forward regimen and n=3, 3-week regimen) or TARGIT-IORT (n=14). Thematic analysis was then carried out by two coders generating 11 themes related to EBRT or TARGIT-IORT. SETTING: Semistructured interviews were conducted virtually via Zoom during February and March 2023. RESULTS: A number of procedural grievances were noted among EBRT patients. EBRT was perceived as being disruptive to normal routines (work, home and travel) and caused discomfort from side effects. TARGIT-IORT was perceived by patients and care partners as the safer option and efficient with minimal if any disruptions to quality of life. The need for timely accessible information to reduce anxieties was noted in both cohorts. CONCLUSIONS: This qualitative study found that patients perceived EBRT as being greatly disruptive to their lives. In contrast, the one-off feature of TARGIT-IORT given while they are asleep during surgery gives them the feeling of stamping out the cancer without conscious awareness. These insights can help healthcare staff and policy-makers further justify the incorporation of the treatment favoured by these patient perceptions (TARGIT-IORT) more widely in routine practice. Further research is planned to explore TARGIT-IORT in more diverse populations and in the 35 countries where it is an established treatment option.

CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER?

BACKGROUND: The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first. AIMS: Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT. METHODS: This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis. RESULTS: Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct. CONCLUSIONS: There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.

Effects of intraoperative different fluid therapy protocols on postoperative renal functions.

PURPOSE: Planning intraoperative fluid therapy in patients undergoing major abdominal surgery is important. It was aimed to define the difference between fluid therapy protocols for renal function, bleeding and postoperative service follow-ups. MATERIALS AND METHODS: This is an observational case-controlled prospective study. Sixty patients aged 18-65 years who had undergone pancreatic surgery between December 2023- February 2023 were included in the study. Liberal (Group 1; n = 30) and targeted fluid therapies (Group 2; n = 30) were administered to the patients. Liberal fluid therapy was planned with 8-10 ml/kg/h crystalloid infusion. The targeted fluid therapy (TFT) group (Group 2; n = 30) began with a 2 ml/kg/h crystalloid infusion at the baseline. Additional fluid boluses were given in 250 ml of colloid infused over 10 min if PVI was > 13% for at least five minutes. The patients were staged using the KDIGO (Kidney Disease: Improving Global Outcomes) criteria. The amount of bleeding during surgery was recorded for both groups. RESULTS: No significant difference was observed in postoperative renal function. A significant difference was observed in the amount of intraoperative bleeding. The amount of bleeding was greater in patients managed with liberal fluid therapy. No significant difference was observed between the groups in the oral intake (hour), drain withdrawal (hour) mobilization (hour) and discharge (day) times and there isn't any statistically significant differance between groups in cost effectivity (p>0.05). CONCLUSION: Kidney function was preserved during individualized targeted fluid therapy using non-invasive haemodynamic monitoring parameters.

Impact of Intraoperative Dexamethasone on Perioperative Blood Glucose Levels: Systematic Review and Meta-Analysis of Randomized Trials.

BACKGROUND: Dexamethasone is associated with increased blood glucose levels that could impact patient outcomes or management. This study aimed to synthesize the available evidence regarding the impact of an intraoperative single dose of dexamethasone on blood glucose levels. METHODS: We searched CENTRAL, MEDLINE, and clinicaltrials.gov for randomized controlled trials (RCTs) comparing a single intraoperative dose of dexamethasone to control in adult patients who underwent noncardiac surgery. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the review was registered in PROSPERO (CRD42023420562). Data were pooled using a random-effects model. We reported pooled dichotomous data using odds ratios (OR) and continuous data using the mean difference (MD), reporting 95% confidence intervals (95% CIs), and corresponding P-values for both. Confidence in the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. As primary outcomes we assessed maximum blood glucose levels measurement and variation from baseline within 24 hours of surgery; blood glucose levels measurement and variation from baseline at 2, 4, 8, 12, and 24 hours after dexamethasone administration. As secondary outcomes, we evaluated insulin requirements and hyperglycemic events. RESULTS: We included 23 RCTs, enrolling 11,154 participants overall. Dexamethasone was associated with a significant increment in blood glucose levels compared to control at all timepoints. The results showed an increase compared to control of 0.37 mmol L-1 (6.7 mg dL-1) at 2 hours (95% CI, 0.16-0.58 mmol L-1 or 2.9-10.5 mg dL-1), 0.97 mmol L-1 (17.5 mg dL-1) at 4 hours (95% CI, 0.67-1.25 mmol L-1 or 12.1-22.5 mg dL-1), 0.96 mmol L-1 (17.3 mg dL-1) at 8 hours (95% CI, 0.55-1.36 mmol L-1 or 9.9-24.5 mg dL-1), 0.90 mmol L-1 (16.2 mg dL-1) at 12 hours (95% CI, 0.62-1.19 mmol L-1 or 11.2-21.4 mg dL-1) and 0.59 mmol L-1 (10.6 mg dL-1) at 24 hours (95% CI, 0.22-0.96 mmol L-1 or 4.0-17.3 mg dL-1). No difference was found between subgroups regarding diabetic status (patients with diabetes versus patients without diabetes) in all the outcomes except 2 (maximum blood glucose levels variation within 24 hours and variation at 4 hours) and dexamethasone dose (4-5 mg vs 8-10 mg) in all the outcomes except 2 (blood glucose levels at 24 hours and hyperglycemic events). CONCLUSIONS: Mean blood glucose levels rise between 0.37 and 1.63 mmol L-1 (6.7 and 29.4 mg dL-1) within 24 hours after a single dose of dexamethasone administered at induction of anesthesia compared to control, but in most patients this difference will not be clinically relevant.

Effect of intra-operative Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation: a randomized controlled trial.

BACKGROUND: Over the last two decades, a large body of literature has focused on studying the prevalence and outcome of the postoperative delirium and sleep disturbance. The aim of this work was to evaluate the effect of intraoperative administration of Magnesium sulphate on the occurrence of post-operative delirium and insomnia in patients undergoing lumbar fixation. METHODS: This prospective randomized controlled trial was carried out on 80 patients indicated for lumbar fixation; 40 of them received conventional general anesthesia with extra administration of intraoperative magnesium sulphate (Mg sulphate group), and the other 40 received conventional general anesthesia only (control group). Both groups were submitted to pre-operative assessment of depression using Beck Depression inventory (BDI) scale, pre-operative assessment of fatigue using a fatigue questionnaire, pre- and post-operative assessment of insomnia using Insomnia severity index (ISI), post-operative assessment of delirium using Memorial delirium assessment scale (MDAS), post-operative assessment of pain using Visual Analogue Scale (VAS), and pre- and post-operative Quantitative electroencephalography (QEEG). RESULTS: Mg sulphate administration, age, pre-operative BDI, pre-operative ISI, and post-operative VAS were independent predictors of post-operative ISI (P-value < 0.001, 0.047, 0.021, < 0.001, and < 0.001 respectively). Age and post-operative VAS were independent predictors of post-operative MDAS (P-value = 0.008, 0.013 respectively). Mg sulphate administration and pre-operative ISI were independent predictors of post-operative VAS (P-value = 0.010, 0.006 respectively). CONCLUSION: There was a significant relationship between intraoperative Mg sulphate administration and both post-operative insomnia and pain in unadjusted and adjusted analysis.

The effect of high-volume intraoperative fluid administration on outcomes among pediatric patients undergoing living donor liver transplantation.

BACKGROUND: Pediatric patients undergoing liver transplantation are particularly susceptible to complications arising from intraoperative fluid management strategies. Conventional liberal fluid administration has been challenged due to its association with increased perioperative morbidity. This study aimed to assess the impact of intraoperative high-volume fluid therapy on pediatric patients who are undergoing living donor liver transplantation (LDLT). METHODS: Conducted at the Children's Hospital of Chongqing Medical University from March 2018 to April 2021, this retrospective study involved 90 pediatric patients divided into high-volume and non-high-volume fluid administration groups based on the 80th percentile of fluid administered. We collected the perioperative parameters and postoperative information of two groups. Multivariable logistic regression was utilized to assess the association between estimated blood loss (EBL) and high-volume FA. Kaplan-Meier survival analysis was used to compare patient survival after pediatric LDLT. RESULTS: Patients in the high-volume FA group received a higher EBL and longer length of stay than that in the non-high-volume FA group. Multivariate logistic regression analysis indicated that hours of maintenance fluids and fresh frozen plasma were significantly associated risk factors for the occurrence of EBL during pediatric LDLT. In addition, survival analysis showed no significant differences in one-year mortality between the groups. CONCLUSIONS: High-volume fluid administration during LDLT is linked with poorer intraoperative and postoperative outcomes among pediatric patients. These findings underscore the need for more conservative fluid management strategies in pediatric liver transplantations to enhance recovery and reduce complications.

Intraoperative radiotherapy: An alternative to whole-breast external beam radiotherapy in the management of highly selective breast cancer: A SEER database analysis.

OBJECTIVE: This study aimed to verify if intraoperative radiotherapy (IORT) can achieve the same survival outcome as whole-breast external beam radiotherapy (EBRT) in early breast cancer after breast-conserving surgery (BCS), and to explore the suitable candidates that can safely receive IORT after BCS. METHODS: Eligible post-BCS patients who received IORT or EBRT were included in the Surveillance, Epidemiology and End Results (SEER) database from 2010 to 2018. Risk factors that affected 5-year overall survival (OS) or breast cancer specific survival (BCSS) were identified by Cox proportional hazards regression analysis. Clinical characteristics, OS, and BCSS were comparatively analyzed between the two treatment modalities. RESULTS: The survival analysis after propensity score matching confirmed that patients who received IORT (n = 2200) had a better 5-year OS than those who received EBRT (n = 2200) (p = 0.015). However, the two groups did not differ significantly in 5-year BCSS (p = 0.381). This feature persisted even after multivariate analyses that took into account numerous clinical characteristics. Although there was no significant difference in BCSS between different subgroups of patients treated with IORT or EBRT, patients over 55 years of age, with T1, N0, non-triple negative breast cancers, hormone receptor-positive, and histologic grade II showed a better OS after receiving IORT. CONCLUSION: In low-risk, early-stage breast cancer, IORT was not inferior to EBRT considering 5-year BCSS and OS. Considering the equivalent clinical outcome but less radiotoxicity, IORT might be a reasonable alternative to EBRT in highly selective patients undergoing BCS.

Intraoperative radiotherapy after neurosurgical resection of brain metastases as institutional standard treatment- update of the oncological outcome form a single center cohort after 117 procedures.

PURPOSE: Stereotactic radiotherapy (SRT) is the predominant method for the irradiation of resection cavities after resection of brain metastases (BM). Intraoperative radiotherapy (IORT) with 50 kV x-rays is an alternative way to irradiate the resection cavity focally. We have already reported the outcome of our first 40 IORT patients treated until 2020. Since then, IORT has become the predominant cavity treatment in our center due to patients´ choice. METHODS: We retrospectively analyzed the outcomes of all patients who underwent resection of BM and IORT between 2013 and August 2023 at Augsburg University Medical Center (UKA). RESULTS: We identified 105 patients with 117 resected BM treated with 50 kV x-ray IORT. Median diameter of the resected metastases was 3.1 cm (range 1.3 - 7.0 cm). Median applied dose was 20 Gy. All patients received standardized follow-up (FU) including three-monthly MRI of the brain. Mean FU was 14 months, with a median MRI FU for patients alive of nine months. Median overall survival (OS) of all treated patients was 18.2 months (estimated 1-year OS 57.7%). The observed local control (LC) rate of the resection cavity was 90.5% (estimated 1-year LC 84.2%). Distant brain control (DC) was 61.9% (estimated 1-year DC 47.9%). Only 16.2% of all patients needed WBI in the further course of disease. The observed radio necrosis rate was 2.6%. CONCLUSION: After 117 procedures IORT still appears to be a safe and appealing way to perform cavity RT after neurosurgical resection of BM with low toxicity and excellent LC.

Intraoperative Dexmedetomidine Use for Enhanced Recovery after Surgery (ERAS) in Cardiac Surgery-Single Center Retrospective Observational Cohort Study.

Background and Objectives: Dexmedetomidine, an alpha-2 agonist, is used as an adjunct to anesthesia in enhanced recovery after surgery (ERAS) programs. One of its advantages is the opioid-sparing effect which can facilitate early extubation and recovery. When the ERAS cardiac society was set in 2017, our facility was already using the ERAS program, in which the "fast-track Anesthesia" was facilitated by the intraoperative infusion of dexmedetomidine. Our objective is to share our experience and investigate the potential impact of intraoperative dexmedetomidine use as a part of the ERAS program on patient outcomes in elective cardiac surgery. Materials and Methods: An observational retrospective cohort study was conducted at a university hospital in Switzerland. The patients who underwent elective cardiac surgery with cardiopulmonary bypass between 1 June 2017 and 31 August 2018 were included in this analysis (n = 327). Regardless of the surgery type, all the patients received a standardized fast-track anesthesia protocol inclusive of dexmedetomidine infusion, reduced opioid dose, and parasternal nerve block. The primary outcome was the postoperative time when the criteria for extubation were met. Three groups were identified: group 0-(extubated in the operating room), group < 6 (extubated in less than 6 h), and group > 6 (extubated in >6 h). The secondary outcomes were adverse events, length of stay in ICU and in hospital, and total hospitalization costs. Results: Dexmedetomidine was well-tolerated, with no significant adverse events reported. Early extubation was performed in 187 patients (57%). Group 3 had a significantly longer length of stay in the ICU (median: 70 h vs. 25 h) and in hospital (17 vs. 12 days), and consequently higher total hospitalization costs (CHF 62,551 vs. 38,433) compared to the net data from the other two groups (p < 0.0001). Conclusions: Our findings suggest that dexmedetomidine can be safely used as part of the opioid-sparing anesthesia protocol in patients undergoing elective cardiac surgery with cardiopulmonary bypass with the potential to facilitate early extubation, shorter ICU and hospital stays, and reduced hospitalization costs.

Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents.

OBJECTIVE: Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN: Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING: The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS: Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION: This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.

Benefits and risks of using laparoscopic ultrasonography versus intraoperative cholangiography during laparoscopic cholecystectomy for gallstone disease: a systematic review and meta-analysis.

BACKGROUND: Intraoperative laparoscopic ultrasonography (LUS) or intraoperative cholangiography (IOC) can be used for visualisation of the biliary tract during laparoscopic cholecystectomy. The aim of this systematic review was to compare use of LUS with IOC. METHODS: PubMed, Embase, the Cochrane Library, and Web of Science were searched (last update: April 2024). PICO: P = patients undergoing intraoperative imaging of the biliary tree during laparoscopic cholecystectomy for gallstone disease; I = intervention: LUS; C = comparison: IOC; O = outcomes: mortality, bile duct injury, retained gallstone, conversion to open cholecystectomy, procedural failure, operation time including imaging time. Included articles were critically appraised using checklists. Conclusions were based on studies without major risk of bias. Meta-analyses were performed using random effects models. Certainty of evidence was assessed according to GRADE. RESULTS: Sixteen non-randomised studies met the PICO. Two before/after studies (594 versus 807 patients) contributed to conclusions regarding mortality (no events; very low certainty evidence), bile duct injury (1 versus 0 events; very low certainty evidence), retained gallstone (2 versus 2 events; very low certainty evidence), and conversion to open cholecystectomy (6 versus 21 events; risk ratio: 0.38 (95% confidence interval: 0.15-0.95); I2 = 0%; low certainty evidence). Seven additional studies, using intra-individual comparisons, contributed to conclusions regarding procedural failure; risk ratio: 1.12 (95% confidence interval: 0.70-1.78; I2 = 83%; very low certainty evidence). No studies reported operation time. Mean imaging time for LUS and IOC, reported in 12 studies, was 4.8‒10.2 versus 10.9‒17.9 min (mean difference: - 7.8 min (95% confidence interval: - 9.3 to - 6.3); I2 = 95%; moderate certainty evidence). CONCLUSION: It is uncertain whether there is any difference in mortality/bile duct injury/retained gallstone using LUS compared with IOC, but LUS may be associated with fewer conversions to open cholecystectomy and is probably associated with shorter imaging time.

Routine intraoperative ureteric stenting for kidney transplant recipients.

BACKGROUND: Major urological complications (MUCs) after kidney transplantation contribute to patient morbidity and compromise graft function. The majority arise from vesicoureteric anastomosis and present early after transplantation. Ureteric stents have been successfully used to treat such complications. A number of centres have adopted a policy of universal prophylactic stenting at the time of graft implantation to reduce the incidence of urine leaks and ureteric stenosis. Stents are associated with specific complications, and some centres advocate a policy of only stenting selected anastomoses. This is an update of our review, first published in 2005 and last updated in 2013. OBJECTIVES: To examine the benefits and harms of routine ureteric stenting to prevent MUCs in kidney transplant recipients. SEARCH METHODS: We contacted the Information Specialist and searched the Cochrane Kidney and Transplant's Specialised Register (up to 19 June 2024) using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA: Our meta-analysis included all randomised controlled trials (RCTs) and quasi-RCTs designed to examine the impact of using stents for kidney transplant recipients. We aimed to include studies regardless of the type of graft, the technique of ureteric implantation, or the patient group. DATA COLLECTION AND ANALYSIS: Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI). Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS: Twelve studies (1960 patients) were identified. One study was deemed to be at low risk of bias across all domains. The remaining 11 studies were of low or medium quality, with a high or unclear risk of bias in at least one domain. Universal prophylactic ureteric stenting versus control probably reduces major urological complications (11 studies: 1834 participants: RR 0.30, 95% CI 0.16 to 0.55; P < 0.0001; I2 = 16%; moderate certainty evidence; number needed to treat (17)); this benefit was confirmed in the only study deemed to be at low risk of bias across all domains. This benefit was also seen for the individual components of urine leak and ureteric obstruction. Universal prophylactic ureteric stent insertion reduces the risk of MUC in the subgroup of studies with short duration (≤ 14 days) of stenting (2 studies, 480 participants: RR 0.39, 95% CI CI 0.21 to 0.72; P = 0.003; I2 = 0%) and where stenting was continued for > 14 days (8 studies, 124 participants: RR 0.22, 95% CI 0.08 to 0.61; P = 0.004; I2 = 29%). It is uncertain whether stenting has an impact on the development of urinary tract infection (UTI) (10 studies, 1726 participants: RR 1.32, 95% CI 0.97 to 1.80; P = 0.07; I² = 60%; very low certainty evidence due to risk of bias, heterogeneity and imprecision). Subgroup analysis showed that the risk of UTI did not increase if short-duration stenting was used (9 days) and that there was no impact on UTI risk when the prophylactic antibiotic regime co-trimoxazole 480 mg/day was used. Stents appear generally well tolerated, although studies using longer stents (≥ 20 cm) for longer periods (> 6 weeks) had more problems with encrustation and migration. There was no evidence that the presence of a stent resulted in recurrent or severe haematuria (8 studies, 1546 participants: RR 1.09, 95% CI 0.59 to 2.00; P = 0.79; I2 = 33%). The impact of stents on graft and patient survival and other stent-related complications remains unclear as these outcomes were either poorly reported or not reported at all. AUTHORS' CONCLUSIONS: Routine prophylactic stenting probably reduces the incidence of MUCs, even when the duration of stenting is short (≤ 14 days). Further high-quality studies are required to assess optimal stent duration. Studies comparing selective stenting and universal prophylactic stenting, whilst difficult to design and analyse, would address the unresolved quality of life and economic issues.

Multicenter survey about leg length discrepancy and total hip arthroplasty: preoperative and intraoperative management.

BACKGROUND: We created a multicenter survey for Italian orthopedic surgeons on how they approach leg length discrepancy (LLD) when dealing with primary total hip arthroplasty. Aim of the study was to show how surgeons manage LLD and follow the literature recommendations during clinical practice. METHODS: The survey was composed of 25 questions divided into four sections: 1-surgeon's profile, 2-preoperative and 3-intraoperative evaluation, and 4-postoperative management. In this paper, we report results to answer Sects. 1 and 2. Absolute and relative frequencies of answers to Sects. 2 and 3 are reported. We divided the participants in subgroups based on the "surgeon's profile" and evaluated difference in the answers given. RESULTS: Absolute and relative frequencies demonstrate low agreement among participants in all phases of LLD management. We demonstrated a statistically significant difference based on the surgeon's profile regarding these questions: radiographic measure of LLD depending on working experience, p = 0.008; digital planning based on surgeons' age, p < 0.001, and workplace, p = 0.026; intraoperative anatomical landmarks based on numbers of procedures per year, p = 0.020; and use of intraoperative X-rays based on working experience, p = 0.002. CONCLUSIONS: LLD is a debated topic with no definitive recommendations. Many decisions still depend on tradition and surgeons' preference.

Effect of intraoperative cold solution irrigation to reduce postoperative pain in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty: a double-blinded randomized controlled trial.

PURPOSE: To compare the postoperative pain score, opioid consumption, and blood loss in knee osteoarthritis patients who underwent unilateral primary total knee arthroplasty with and without intraoperative cold solution irrigation. METHOD: In total, 70 knee osteoarthritis patients were randomly included in the study and allocated into 2 groups. The first group was irrigated intraoperatively with a cold solution and the second group was irrigated intraoperatively with a room-temperature solution. RESULTS: The cold solution group showed significantly lower pain scores (numerical rating scale, NRS) at 28 h postoperatively (p = 0.047). There were no significant differences in opioid consumption or blood loss between the groups. CONCLUSIONS: Intraoperative cold solution irrigation in unilateral primary total knee arthroplasty patients may provide the benefit of early postoperative pain reduction for up to 28 h but has no effect in terms of reducing opioid consumption or blood loss. TRIAL REGISTRATION: The trial was registered in the Thai Clinical Trials Registry (TCTR) Trial registration number ID: TCTR20200706001 on 06/07/2020.

Timing of Intraoperative Transitions of Care Among Anesthesiologists Is Not Associated With Postoperative Adverse Outcomes: Retrospective Cohort Study.

BACKGROUND: The majority of published research suggests that anesthesia handovers during major surgical procedures are associated with unintended harmful consequences. It is still unclear if the number or quality of the transition of care is the main driver of the adverse outcomes. There is even less data if the timing of the anesthesiologist handovers during the critical portion of the anesthetic continuum (induction or emergence versus surgical period) plays a role in patient outcomes. Therefore, we investigated if the anesthesiologist handovers during induction and emergence are associated with adverse patient outcomes. METHODS: This retrospective investigation included noncardiac surgical procedures occurring between January 1, 2012 and December 31, 2019 that had exactly 1 attending anesthesiologist handover. We categorized transitions of care between attending anesthesiologists as being before incision, between incision and closing, and after closing. Our primary outcome was a composite of 6 categories of surgical complications and in-hospital mortality. We created logistic generalized estimating equation models to estimate the average relative effect odds ratio between each pair of the 3 transition timing groups across the components of the composite outcome. Inverse probability of treatment weights were used to mitigate confounding on a host of baseline variables. We used Bonferroni correction to adjust for multiple comparisons between the transition groups. RESULTS: In total, we studied 36,937 procedures with exactly 1 attending anesthesiologist handover. Of these records, 4370 had the transition during induction, 24,999 between incision and closure, and 7568 during emergence. No differences were found between the transition periods and the composite outcome. The estimated average relative effect odds ratio (98.3% confidence interval [CI]) across the components of the composite outcome was as follows: (1.0002 [0.81-1.24], P = .99) between the induction and surgical period; (1.10 [0.87-1.40], P = .32) between the induction and emergence periods; and (0.91 [0.79-1.04], P = .08) between the emergence and surgical periods. CONCLUSIONS: Timing of intraoperative handover among attending anesthesiologists during noncardiac surgery is not associated with adverse patient outcomes.