COVID-free surgical pathways for treating patients with acute calculous cholecystitis: a retrospective comparative study.

Introduction: During the Sars-Cov-2 crisis, some of the resources committed to emergency surgery services were transiently reallocated to the care of patients with severe COVID-19, preserving immediate treatment of mostly non-deferrable conditions. Moreover, the fear of contracting infections or hindering the treatment of critical COVID-19 patients has caused many individuals to defer seeking emergency care. This situation has then possibly modified the standard of care of some common surgical conditions and the relative outcomes. Our aims was to highlight any difference in surgical outcomes in patients treated for acute cholecystitis before and during the COVID-19 outbreak. Method: This is a retrospective study on a prospectively collected database that included all consecutive patients treated for acute cholecystitis from March 2019 to February 2021 at the Lugano Regional Hospital, a COVID-free hospital for general surgery patients. Patients were divided into pre-and post-COVID-19 outbreak groups. We collected thorough clinical characteristics and intra-and postoperative outcomes. Results: We included 124 patients, of which 60 and 64 were operated on before and after the COVID-19 outbreak respectively. The two groups resulted similar in terms of patients' clinical characteristics (age, gender, body mass index, ASA score, and comorbidities). Patients in the post-outbreak period were admitted to the hospital 0.7 days later than patients in the pre-outbreak period (3.8 ± 6.0 days vs. 3.1 ± 4.1 days, p = 0.453). Operative time, recovery room time, complications, and reoperations resulted similar between groups. More patients in the post-outbreak period received postoperative antibiotic therapy (63.3% vs. 37.5%, p = 0.004) and for a longer time (6.9 ± 5.1 days vs. 4.5 ± 3.9 days, p = 0.020). No significant histopathological difference was found in operatory specimens. Discussion: Despite more frequent antibiotic therapy that suggests eventually worse inflammatory local status, our results showed similar outcomes for patients treated for acute cholecystitis before and during the COVID-19 pandemic. The local COVID management, reallocating resources, and keeping COVID-free hospitals was key to offering patients a high standard of treatment.

Safety and feasibility of emergency robot-assisted transabdominal preperitoneal repair for the treatment of incarcerated inguinal hernia: A retrospective study.

BACKGROUND: Few studies assessed robotic in emergency setting and no solid evidence was demonstrated. The aim of this study was to evaluate the feasibility and safety of robot-assisted transabdominal preperitoneal (R-TAPP) repair for the treatment of incarcerated inguinal hernia. METHODS: We retrospectively searched from a prospectively maintained database patients who underwent R-TAPP or open surgery for incarcerated inguinal hernias from January 2018 to March 2023. The primary endpoint was to assess safety and feasibility of the R-TAPP compared to the standard approach. For eligible patients, data was extracted and analyzed using a propensity score-matching (PSM). RESULTS: Thirty-four patients were retrieved from our database, 15 underwent R-TAPP, while 19 underwent open surgery. Mean age was 73.1 ± 14.6 years, 30 patients (88.2%) were male and mean BMI was 23.5 ± 3.2 kg/m2. No intraoperative complication occurred. Three cases requiring small bowel resection were all in the open surgery group (p = 0.112). The operative time was 108 ± 31 min versus 112 ± 31 min in the R-TAPP and open surgery groups (p = 0.716). Seven postoperative complications occurred, only one classified as severe was in the open surgery group. The length of hospital stay was 2.9 ± 1.8 in the R-TAPP versus 4.2 ± 2.3 min in the open surgery group (p = 0.077). PSM analysis showed similar postoperative outcomes and costs in both groups. CONCLUSIONS: Despite its limitations, our study appears to endorse the safety and feasibility of the robotic-assisted treatment for incarcerated inguinal hernia. This approach yielded comparable results to open surgery, albeit in a limited number of patients, suggesting it might be a viable alternative.

Concomitant training in robotic and laparoscopic liver resections of low-to-intermediate difficulty score: a retrospective analysis of the learning curve.

In the setting of minimally invasive liver surgery (MILS), training in robotic liver resections (RLR) usually follows previous experience in laparoscopic liver resections (LLR). The aim of our study was to assess the learning curve of RLR in case of concomitant training with LLR. We analyzed consecutive RLRs and LLRs by a surgeon trained simultaneously in both techniques (Surg1); while a second surgeon trained only in LLRs was used as control (Surg2). A regression model was used to adjust for confounders and a Cumulative Sum (CUSUM) analysis was carried out to assess the learning phases according to operative time and difficulty of the procedures (IWATE score). Two-hundred-forty-five procedures were identified (RobSurg1, n = 75, LapSurg1, n = 102, LapSurg2, n = 68). Mean IWATE was 4.0, 4.3 and 5.8 (p < 0.001) in each group. The CUSUM analysis of the adjusted operative times estimated the learning phase in 40 cases (RobSurg1), 40 cases (LapSurg1), 48 cases (LapSurg2); for IWATE score it was 38 cases (RobSurg1), 33 cases (LapSurg1), 38 cases (LapSurg2) respectively. Our preliminary experience showed a similar learning curve of 40 cases for low and intermediate difficulty RLR and LLR. Concomitant training in both techniques was safe and may be a practical option for starting a MILS program.

Switching from robotic-assisted extended transabdominal preperitoneal (eTAPP) to totally extraperitoneal (eTEP) hernia repair for umbilical and epigastric hernias.

Our study aimed to assess the safety and effectiveness of the robotic-assisted extended totally extraperitoneal (eTEP) repair compared to transabdominal preperitoneal (eTAPP) repair with a suprapubic trocar insertion to treat umbilical and epigastric hernias. On a prospectively maintained database, we identified patients who underwent either eTEP or eTAPP for treating umbilical and epigastric hernias. During the study period, 53 patients were included, 32 in the eTEP group and 21 in the eTAPP group. The mean age was 59.0 ± 13.9 years, 45 patients (84.9%) were male, and the mean BMI was 28.0 ± 5.9 kg/m2. Most hernias were umbilical (81.1%) and primary (83.0%). The operative time for eTEP was slightly shorter than for eTAPP (106 ± 43 min vs. 126 ± 74 min, p = 0.232). Postoperatively, only one case of bleeding and one seroma were recorded. No complication occurred during a mean follow-up of 11.3 ± 6.4 months in the eTEP group and 20.5 ± 9.7 months in the eTAPP group. In conclusion, our study showed that the eTEP with suprapubic approach was safe and feasible in the treatment of epigastric and umbilical hernias. According to our experience, shorter operative time, integrity of the posterior layers and increased overlap size are the main surgical reasons of switching from eTAPP to eTEP.

Laparoscopic vs. ultrasound-guided transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: The transversus abdominis plane block (TAPB) is effective for postoperative pain management in patients undergoing colorectal surgery. However, evidence regarding the optimal delivery method, either laparoscopic (L-TAPB) or ultrasound-guided (U-TAPB) is lacking. Our study aimed to compare the effectiveness of these delivery methods. METHODS: We carried out a literature search of PubMed, Cochrane Library, Web of Science, and Google Scholar databases to include randomized studies comparing patients receiving either L-TAPB or U-TAPB during minimally invasive colorectal surgery. The primary endpoint was opioid consumption in the first 24 h after surgery. Risk of bias was assessed with the RoB-2 tool. Effect size was estimated for each study with 95% confidence interval and overall effect measure was estimated with a random effect model. RESULTS: The literature search revealed 294 articles, of which four randomized trials were eligible. A total of 359 patients were included, 176 received a L-TAPB and 183 received a U-TAPB. We established the non-inferiority of L-TAPB, as the absolute difference of - 2.6 morphine-mg (95%CI - 8.3 to 3.0) was below the pooled non-inferiority threshold of 8.1 morphine-mg (low certainty level). No difference in opioid consumption was noted at 2, 6, 12, and 48 h (low to very low certainty level). Postoperative pain, nausea and vomiting were similar between groups at different timepoints (low to very low certainty level). No TAPB-related complications were recorded. Finally, the length of hospital stay was similar between groups. CONCLUSION: For postoperative multimodal analgesia both L-TAPB and U-TAPB may result in little to no difference in outcome in patients undergoing colorectal surgery. Registration Prospero CRD42023421141.

Long-term outcomes in elderly patients after elective surgery for colorectal cancer within an ERAS protocol: a retrospective analysis.

PURPOSE: The number of elderly patients with a diagnosis of colorectal cancer (CRC) is increasing. Considering short life expectancy and multiple comorbidities, surgery may not always be the best treatment option. METHODS: We included all consecutive patients aged 80 years and older who underwent elective resection for CRC following Enhanced Recovery after Surgery (ERAS) protocol between January 2011 and May 2021. The primary endpoint was overall survival, secondary endpoints were 30-day morbidity, and the rate of return to pre-operative living conditions 3 months after surgery. RESULTS: Ninety-four patients were included. Mean age was 84.6 ± 3.6 years, 49 patients (52%) were female. Most patients (77.6%) were ASA score ≥ 3. Laparoscopic resections were performed in 85 patients (90.4%), involving 69 (73.4%) colonic and 25 (26.6%) rectal resections. A stoma was constructed in 22 patients (23%), and reversed in 12 (54.5%). Twenty-two patients (23.4%) experienced a Clavien-Dindo ≥ 3 complication, and 2 patients (2.1%) died. The median length of hospital stay was 8 (interquartiles: 6-15) days. Sixty-six patients (70.2%) were discharged home directly and 26 (27.7%) to rehabilitation or postacute care institutes. At three months after surgery, eighty-two patients (96.5%) returned to their pre-operative living conditions directly or after short-term rehabilitation. Mean follow-up was 53 ± 33 months, estimated 5-year overall survival was 60.3% (95%CI 49.5-71.1%), and disease-free survival was 86.3% (95%CI 78.1-94.4%). CONCLUSIONS: Our study suggests that elderly patients undergoing elective surgery have a high potential to return to preoperative living conditions and good overall- and disease-free survivals, despite significant postoperative morbidity.

Laparoscopic-Assisted Transversus Abdominis Plane (TAP) Block Versus Port-Site Infiltration with Local Anesthetics in Bariatric Surgery: a Double-Blind Randomized Controlled Trial.

BACKGROUND: The transversus abdominis plane (TAP) block has shown great potential usefulness in the management of postoperative pain; however, there is lacking evidence regarding its use in bariatric surgery. This randomized double-blind trial was aimed at comparing the effectiveness of the TAP block and port-site infiltration (PSI) in patients undergoing bariatric surgery. METHODS: We included patients ≥ 18 years old undergoing bariatric surgery. From July 2020 to July 2021, all eligible patients were randomized to receive either laparoscopic-assisted TAP block or PSI. Demographic and clinical data were collected and analyzed. RESULTS: During the study period, we included 113 patients. Fifty-one were allocated to the TAP block group and 62 to the PSI group. The mean age was 47.9 ± 11.2 years, 88 (77.9%) patients were female, and mean BMI was 40.5 ± 5.9 kg/m2. Operative time was 110 ± 42 min vs. 114 ± 41 min in the TAP block and PSI groups (p = 0.658). At 24 h after surgery, pain on the VAS was 2.5 ± 2.6 vs. 2.3 ± 2.1 (p = 0.661). No significant difference between the groups was noted at 3, 6, 12, and 18 h. Also, opioid and antiemetic consumption, the length of stay (3.4 ± 1.5 days vs. 3.2 ± 1.1 days, p = 0.392), and satisfaction score (154 ± 10 pts vs. 154 ± 16 pts, p = 0.828) were similar in the two groups. CONCLUSIONS: Patients undergoing bariatric surgery and receiving either the TAP block or the PSI had similar postoperative pain, nausea, length of stay, and satisfaction. As PSI is technically easier and more reproducible, it might be the first choice for postoperative multimodal analgesia in bariatric surgery.

Laparoscopic versus ultrasound-guided transversus abdominis plane block in colorectal surgery: a non-inferiority, multicentric randomized double-blinded clinical trial.

AIM: The aim of this study was to assess if laparoscopic-assisted transversus abdominis plane (TAP) block (L-TAPB) is as efficient as ultrasound-guided TAP block (U-TAPB) in postoperative pain control. METHOD: In all, 112 patients scheduled for elective laparoscopic colon resection from February 2018 to December 2021 at two Swiss hospitals were included and randomized in a 1:1 ratio before surgery with either L-TAPB or U-TAPB. The primary end-point was the non-inferiority of the L-TAPB compared to U-TAPB with regard to the total opioid consumption within the first 24 h after surgery. Data regarding patients' characteristics, opioid consumption, pain on the visual analogue scale, operative and anaesthesia induction time, complications and length of stay were collected and analysed. RESULTS: Fifty-five patients were allocated to the L-TAPB and fifty-seven to the U-TAPB. No significant difference was found in the overall dose of opioids within 24 h, and the non-inferiority of the L-TAPB was confirmed. There were almost twice as many patients in the L-TAPB group requesting opioid reserves compared to the U-TAPB group (54.5% vs. 29.8%, P = 0.008). The anaesthesia induction time was significantly longer in the U-TAPB group (17 ± 11 min vs. 23 ± 12 min, P = 0.014). For all other variables (pain on the visual analogue scale, opioid consumption, need of epidural analgesia, operating time, postoperative complications and hospital stay) no statistically significant difference between the L-TAPB and the U-TAPB groups was noted. CONCLUSION: Our results showed the non-inferiority of the laparoscopic delivery compared to ultrasound-guided administration of the TAP block, with the advantage of not affecting anaesthesia times. STUDY REGISTRATION NUMBER: 2017-02017 CE 3294, ClinicalTrials.gov identifier NCT04575233.

Six Sigma can significantly reduce costs of poor quality of the surgical instruments sterilization process and improve surgeon and operating room personnel satisfaction.

Operating room (OR) management is a complex multidimensional activity combining clinical and managerial aspects. This longitudinal observational study aimed to assess the impact of Six-Sigma methodology to optimize surgical instrument sterilization processes. The project was conducted at the operating theatre of our tertiary regional hospital during the period from July 2021 to December 2022. The project was based on the surgical instrument supply chain analysis. We applied the Six Sigma lean methodology by conducting workshops and practical exercises and by improving the surgical instrument process chain, as well as checking stakeholders' satisfaction. The primary outcome was the analysis of Sigma improvement. Through this supply chain passed 314,552 instruments in 2022 and 22 OR processes were regularly assessed. The initial Sigma value was 4.79 ± 1.02σ, and the final one was 5.04 ± 0.85σ (SMD 0.60, 95%CI 0.16-1.04, p = 0.010). The observed improvement was estimated in approximately $19,729 of cost savings. Regarding personnel satisfaction, 150 questionnaires were answered, and the overall score improved from 6.6 ± 2.2 pts to 7.0 ± 1.9 pts (p = 0.013). In our experience the application of the Lean Six Sigma methodology to the process of handling the surgical instruments from/to the OR was cost-effective, significantly decreased the costs of poor quality and increased internal stakeholder satisfaction.

Assessment of gastric pouch blood supply with indocyanine green fluorescence in conversional and revisional bariatric surgery: a prospective comparative study.

Our study aimed to evaluate the usefulness of indocyanine green (ICG) angiography during conversional or revisional bariatric surgery. We prospectively enrolled all patients scheduled for reoperative bariatric surgery with gastric pouch resizing and ICG assessment and we compared them with a retrospective series of similar patients who did not receive ICG. The primary outcome was the rate of intraoperative change in the surgical strategy due to the ICG test. We included 32 prospective patients receiving intraoperatively an ICG perfusion test and 48 propensity score-matched controls. The mean age was 50.7 ± 9.7 years, 67 (83.7%) patients were female, and the mean BMI was 36.8 ± 5.3 kg/m2. The patient characteristics were similar in both groups. The ICG angiography was successfully conducted in all patients, and no change of the surgical strategy was necessary. Postoperative complications were similar in both groups (6.2% vs. 8.3%, p = 0.846), as well as operative time (125 ± 43 vs. 133 ± 47 min, p = 0.454) and length of hospital stay (2.8 ± 1.0 vs. 3.3 ± 2.2 days, p = 0.213). Our study suggested that ICG fluorescence angiography might not have been useful for assessing the blood supply of the gastric pouch in patients who underwent reoperative bariatric surgery. Therefore, it remains uncertain whether the application of this technique is indicated.

Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review

Abstract Background and objectives: Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (‟regional anesthesia" OR ‟nerve block") AND (‟complications" OR ‟nerve lesion" OR ‟nerve damage" OR ‟nerve injury"). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results: Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusion: Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature

Abstract Background and objectives: In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting. Methods: A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used). Results: One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result. Conclusions: Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis

Abstract Background and objectives: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. Methods: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. Results: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random ''first come -first serve'' basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). Conclusion: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

Intestinal ischemia due to internal hernia beneath the right external iliac artery after laparoscopic hysterectomy and lymphadenectomy: A case report.

INTRODUCTION AND IMPORTANCE: The occurrence of an internal hernia beneath the external iliac artery is rare but may occur after pelvic lymphadenectomy. The challenging treatment of this rare condition should be tailored to the patient's clinical and anatomical characteristics. CASE PRESENTATION: We present the case of a 77-year-old woman with previous history of laparoscopic hysterectomy and adnexectomy with extended pelvic lymphadenectomy for endometrial cancer. The patient was admitted in the emergency department because of severe abdominal pain and a computed tomography scan showed signs of internal hernia. The laparoscopy confirmed such a finding below the right external iliac artery. A small bowel resection was deemed necessary and the defect was closed with an absorbable mesh. The post-operative course was uneventful. CLINICAL DISCUSSION: Internal hernia beneath the iliac artery is a rare condition after pelvic lymphadenectomy. The first challenge is the hernia reduction, which can be safely carried out laparoscopically. Secondly, a patch or a mesh should be used to close the defect if a primary peritoneal suture is not feasible, but it requires to be fixed in the small pelvis. The use of absorbable material is a valuable option and should leave a fibrotic area that covers the hernia defect. CONCLUSION: A strangulated internal hernia beneath the external iliac artery is a possible complication after extensive pelvic lymph node dissection. The laparoscopic approach to treat bowel ischemia and to close the peritoneal defect with a mesh, should reduce as much as possible the risk of internal hernia recurrence.

Impact of Multidisciplinary Team Meetings on Decision Making in Vascular Surgery: A Prospective Observational Study.

OBJECTIVE: This cohort study aimed to prospectively determine the impact of multidisciplinary team meetings (MDTs) on treatment plans in vascular patients. METHODS: The weekly MDT at the institution consisted of a structured discussion of vascular cases in the presence of at least one representative of each specialty from vascular surgery, angiology, and interventional radiology. Participants were asked to examine the cases entered on the digital MDT platform and to fill in forms with a detailed open text treatment recommendation for each patient. Individual recommendations were compared with the final MDT decision, which was based on a shared decision after discussion of clinical and radiological data. The primary endpoint was the agreement rate. The rate of decision implementation was determined to verify the adherence to MDT recommendations. RESULTS: Four hundred consecutive case discussions in 367 patients between November 2019 and March 2021 were included, excluding patients needing urgent treatment, yielding MDT discussion in 88.5% of carotid artery cases, 83% of aorto-iliac cases, and 51.7% of peripheral arterial cases, which included 56.9% of the chronic limb threatening ischaemia cases. The overall average agreement rate was 71% ± 41%. Analysis according to the specialty of the attending physician showed agreement rates of 82% ± 30% for senior vascular surgeons, 62% ± 44% for junior vascular surgeons, 71% ± 43% for interventional radiologists, 58% ± 50% for angiologists (p < .001), and 75% ± 38% considering only senior practitioners. The inter-rater agreement, resulted in kappa coefficients of 0.60 - 0.68 for senior vascular surgeons, 0.29 - 0.31 for junior vascular surgeons, 0.39 - 0.52 for interventional radiologists, and 0.25 for angiologists. The MDT treatment decision was implemented in 353 (96.2%) cases. CONCLUSION: The impact of MDT discussion on treatment recommendations and the adherence to MDT recommendations were significant and in line with results reported from other specialties.

Partial staple line reinforcement with synthetic buttressing material in laparoscopic sleeve gastrectomy: a propensity score-matched analysis.

PURPOSE: Staple line leakage (SLL) and staple line bleeding (SLB) are the most relevant postoperative complications of sleeve gastrectomy (SG). It is controversial whether and which method of staple line reinforcement (SLR) can best reduce these complications. The primary objective of this study was to investigate whether reinforcement of the most proximal part of the staple line with synthetic buttressing material, a strategy we termed partial SLR (p-SLR), reduces the 30-day incidence of SLL. METHODS: A retrospective search of medical records of all bariatric patients from 2010 to 2019 was performed. Patients who underwent SG with either p-SLR or non-SLR were included. Intraoperative and postoperative outcomes were analyzed before and after propensity score matching (PSM). RESULTS: Data from 431 patients were analyzed (364 in the p-SLR group and 67 in the non-SLR group). No difference in the 30-day incidence of SLL was observed between the two groups. The 30-day incidence of SLB (1.1% vs. 6.0% in the p-SLR and non-SLR groups, respectively) was significantly lower in the p-SLR group. These results were confirmed by PSM analysis. CONCLUSION: Partial staple line reinforcement with synthetic buttressing material does not reduce the 30-day incidence of SLL. Although our analysis showed a significant reduction in the 30-day incidence of SLB in the p-SLR group, this result should be interpreted with caution.

Perioperative costs of local or regional anesthesia versus general anesthesia in the outpatient setting: a systematic review of recent literature.

BACKGROUND AND OBJECTIVES: In this systematic review, we carried out an assessment of perioperative costs of local or regional anesthesia versus general anesthesia in the ambulatory setting. METHODS: A systematic literature search was conducted to find relevant data on costs and cost-effectiveness analyses of anesthesia regimens in outpatients, regardless of the medical procedure they underwent. The hypothesis was that local or regional anesthesia has a lower economic impact on hospital costs in the outpatient setting. The primary outcome was the average total cost of anesthesia calculated on perioperative costs (drugs, staff, resources used). RESULTS: One-thousand-six-hundred-ninety-eight records were retrieved, and 28 articles including 27,581 patients were selected after reviewing the articles. Data on the average total costs of anesthesia and other secondary outcomes (anesthesia time, recovery time, time to home readiness, hospital stay time, complications) were retrieved. Taken together, these findings indicated that local or regional anesthesia is associated with lower average total hospital costs than general anesthesia when performed in the ambulatory setting. Reductions in operating room time and postanesthesia recovery time and a lower hospital stay time may account for this result. CONCLUSIONS: Despite the limitations of this systematic review, mainly the heterogeneity of the studies and the lack of cost-effectiveness analysis, the economic impact of the anesthesia regimes on healthcare costs appears to be relevant and should be further evaluated.

Identification and economic burden of main adverse events of nerve injuries caused by regional anesthesia: a systematic review.

BACKGROUND AND OBJECTIVES: Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. METHODS: According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: ("regional anesthesia" OR "nerve block") AND ("complications" OR "nerve lesion" OR "nerve damage" OR "nerve injury"). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. RESULTS: Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. CONCLUSIONS: Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

Contribution margin per hour of operating room to reallocate unutilized operating room time: a cost-effectiveness analysis.

BACKGROUND AND OBJECTIVES: Contribution margin per hour (CMH) has been proposed in healthcare systems to increase the profitability of operating suites. The aim of our study is to propose a simple and reproducible model to calculate CMH and to increase cost-effectiveness. METHODS: For the ten most commonly performed surgical procedures at our Institution, we prospectively collected their diagnosis-related group (DRG) reimbursement, variable costs and mean procedural time. We quantified the portion of total staffed operating room time to be reallocated with a minimal risk of overrun. Moreover, we calculated the total CMH with a random reallocation on a first come-first served basis. Finally, prioritizing procedures with higher CMH, we ran a simulation by calculating the total CMH. RESULTS: Over a two-months period, we identified 14.5 hours of unutilized operating room to reallocate. In the case of a random "first come-first serve" basis, the total earnings were 87,117 United States dollars (USD). Conversely, with a reallocation which prioritized procedures with a high CMH, it was possible to earn 140,444 USD (p < 0.001). CONCLUSION: Surgical activity may be one of the most profitable activities for hospitals, but a cost-effective management requires a comprehension of its cost profile. Reallocation of unused operating room time according to CMH may represent a simple, reproducible and reliable tool for elective cases on a waiting list. In our experience, it helped improving the operating suite cost-effectiveness.

The performance of levothyroxine tablet is impaired by bariatric surgery.

OBJECTIVE: The aim was to evaluate if bariatric surgery can affect the LT4 performance. The endpoints were the following: 1) difference between LT4 daily dose before and 1 year after surgery, 2) difference between LT4 dose per weight before and 1 year after surgery, 3) difference among LT4 preparations. METHODS: The study period was between January 2018 and May 2022. Inclusion criteria were a) adults undergone bariatric surgery, b) with proven autoimmune hypothyroidism, c) on LT4 therapy before bariatric surgery, d) using any commercialized LT4 preparation. Excluded were patients a) proven to have or suspected for pre-surgical intestinal malabsorption, b) with other potential interfering factors on LT4 absorption; c) with heart, renal, and/or hepatic failure, d) with recent/current infection/inflammation, e) in pregnancy, f) with incomplete data about LT4 therapy. RESULTS: According to the selection criteria, 40 patients were included. Both TSH and LT4 daily doses were not significantly different with respect to baseline values. On the contrary, the LT4 dose per weight was significantly increased, especially in RYGB patients. An increased LT4 dose per weight was observed with the reduction of weight. CONCLUSION: One year after bariatric surgery 1) the daily dose of LT4 remains unchanged, and 2) despite the significant weight reduction, LT4 dose per weight increases. Most data are referred to LT4 tablet and the performance of LT4 caps should be further investigated.