Perioperative airway complications in infants and children with Crouzon and Pfeiffer syndromes: A single-center experience.

BACKGROUND: Crouzon and Pfeiffer syndromes are rare genetic disorders characterized by craniosynostosis, exorbitism, and maxillary hypoplasia. Patients with these syndromes frequently require general anesthesia for various diagnostic and surgical procedures and may present a challenge to anesthetists with regard to airway management. AIMS: The primary aim of this study was to determine the incidence, timing, and management of perioperative upper airway obstruction in infants and children with Crouzon and Pfeiffer syndromes. The secondary aim was to determine the degree of difficulty in performing endotracheal intubation. METHODS: A retrospective review of 812 anesthetic encounters in 67 patients was conducted. The following were recorded: timing and management of episodes of perioperative upper airway obstruction, from induction of anesthesia to discharge from recovery, degree of difficulty with laryngoscopy using the Cormack-Lehane grading system and number of intubation attempts required, patient demographics, respiratory comorbidity, surgical procedure, and anesthetic airway management techniques. RESULTS: Upper airway obstruction at induction of anesthesia was very common, with an incidence of 31% (167/542 anesthetic encounters affecting 54 patients). In a quarter of these incidents, bag-valve-mask ventilation was challenging, but a laryngeal mask airway was almost always effective. Upper airway obstruction on emergence from anesthesia was less common, with an incidence of 2.7% (14/515 anesthetic encounters affecting 10 patients). Contributing factors included patient comorbidity (obstructive sleep apnea, nasal stenosis) and the nature of surgery (craniofacial or airway procedures). Intubation was rarely difficult in this cohort, with 85% of laryngoscopies rated Cormack-Lehane grade 1 or 2 (n = 373), and 89% of intubations successful on the first attempt (n = 306). CONCLUSIONS: Upper airway obstruction at induction of anesthesia is common in patients with Crouzon and Pfeiffer syndrome. These patients are likely to present some difficulties with perioperative airway management, especially bag-valve-mask ventilation, but rarely endotracheal intubation.

Making the experience of elective surgery better.

Objective Patient experience is one of the three pillars of quality in healthcare; improving it must be a key aim if we are to make the overall quality of the healthcare we provide better. Methods We devised a quality improvement project to improve the patient experience of elective surgery. We conducted surveys of patients and assessed their experience by using semistructured interviews and patient questionnaires. We gathered data about their overall satisfaction, fasting times and their communication with staff. We used this information to inform strategies aimed at improving patient experience. Results Our initial results showed that patients who had their operations later in the day were significantly less likely to report a positive experience. We found the main reasons for this were long waiting times, poor communication and prolonged fasting. We implemented changes over 'Plan, Do, Study, Act' cycles, including (1) staggering patient arrival times, (2) introducing the concept of the 'Golden Patient', (3) having a single point of contact on the day surgery unit to communicate between theatre staff and patients, (4) using the WHO checklist to finalise list order, and (5) altering patient information letters to include the possibility of a wait on the day of surgery. Conclusion This project increased the percentage of patients reporting an 'Excellent' or 'Good' experience from 65% to 96%. In addition to improving our patients' experience, our project has also delivered shorter waiting times, better dissemination of information and fewer patients reporting hunger or thirst.

Linear-stapled versus circular-stapled laparoscopic gastrojejunal anastomosis in morbid obesity: meta-analysis.

BACKGROUND: The study aims to provide a pooled analysis of individual small trials comparing linear-stapled versus circular-stapled laparoscopic gastrojejunal (GJ) anastomosis in morbid obesity surgery. METHODS: A systematic literature search of Medline, Embase, and Cochrane library databases was performed. Primary outcomes were GJ leak and stricture. Secondary outcomes were operative time, length of hospital stay, postoperative bleeding, wound infection, marginal ulcers, and estimated weight loss. Pooled odds ratios were calculated for categorical outcomes and weighted mean differences for continuous outcomes. RESULTS: Nine trials were included comprising 9374 patients (2946 linear vs. 6428 circular). Primary outcome analysis revealed a statistically significant increase in the rate of GJ stricture associated with circular-stapled anastomosis. A significantly reduced rate of wound infection, bleeding, and operative time associated with linear stapling was also found. No significant differences appeared for the other outcomes. CONCLUSIONS: This pooled analysis recommends the preferential use of the linear stapling technique over circular stapling.

Laparoscopic versus open appendicectomy in obese patients.

BACKGROUND: Although there appears to be no outright benefit of laparoscopic versus open surgery for acute appendicitis in the general population, it has been suggested that in obese patients a laparoscopic approach may offer more conclusive gains. The aim of this pooled analysis of comparative studies was to evaluate clinical outcome following laparoscopic and open appendicectomy in the obese population. METHODS: A systematic literature search of MEDLINE, Embase, Web of Science and the Cochrane Library databases was performed. Primary outcomes were length of operation (min) and length of hospital stay (days). Secondary outcomes were presence of post-operative complications, wound and intra-abdominal complications. Weighted mean differences were calculated to assess the size of the effect of laparoscopic appendicectomy on continuous variables and Pooled odds ratio were calculated for discrete variables. RESULTS: 2309 appendicectomies were included in this analysis, 1122 laparoscopic and 1187 open appendicectomies. Analysis of primary outcome measures revealed a shorter length of post-operative stay associated with laparoscopic appendicectomy (weighted mean difference = -1.26; 95% confidence interval = -2.36 to -0.16; p = 0.02). There was no significant difference between the groups for length of operation, post-operative complications, intra-abdominal or wound complications. CONCLUSION: The results of this pooled analysis indicate that laparoscopic appendicectomy may be beneficial in the obese population with a shorter length of hospital stay, and a similar incidence of post-operative complications.