Antithrombotic therapy and spinal surgery: a retrospective cohort study of 289 consecutive elderly patients with degenerative lumbar stenosis.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a disabling degenerative process of the spine, mainly affecting older patients. LSS manifests with low-back and leg pain and neurogenic claudication. Disability and impairment in activities of daily living are consequences of the progressive narrowing of the lumbar spinal canal. Surgical decompression has been shown to be superior to conservative management. Nonetheless, intraoperative and postoperative blood loss in elderly patients taking antiplatelet or anticoagulant drugs owing to cardiovascular comorbidities may be a special issue. This study describes and compares early outcomes after surgical procedures in different groups of patients receiving antithrombotic drugs. METHODS: The authors' study retrospectively recruited 289 consecutive patients aged ≥ 65 years who received lumbar decompression for spinal stenosis between January 2021 and May 2022. First, 183 patients taking antiplatelet therapy were divided into two groups according to the rationale for use: primary versus secondary prophylaxis of cardiovascular events (group 1 vs group 2). Primary prevention was stopped preoperatively, or secondary prevention was not discontinued during the perioperative period. Secondly, 106 patients who were not taking antiplatelet mediation were divided into two groups, depending on whether preoperative low-molecular-weight heparin had not been administered or had been (group A vs group B). Intraoperative blood loss, surgical time, and postoperative hospitalization were analyzed. RESULTS: No significant statistical differences were observed between groups 1 and 2 in terms of intraoperative blood loss and time of surgery, or between groups A and B in terms of all analyzed variables. No early or delayed complications were observed, perioperatively or during the postoperative 3-month follow-up period. CONCLUSIONS: The results of this study suggest that the use of anticoagulant and antiplatelet therapies in elective decompressive surgery could be devoid of early complications and could be safely continued perioperatively.

Standardization of intra- and peri-operative management to reduce postoperative drainage time after major thoracoscopic pulmonary resections.

Background: It is important to reduce the postoperative drainage time after thoracic surgery to relieve postoperative pain and facilitate patient mobilization. We standardized intra- and peri-operative management of major, thoracoscopic pulmonary resections in February 2019. In this study, we investigated whether this standardization reduced the postoperative drainage time. Moreover, we examined how such management affected re-admission within 30 days after operation (because of pleural complications). Methods: Between May 2012 and February 2022, 815 patients with malignant or benign disease underwent major thoracoscopic pulmonary resections in our department. The patients were classified into two groups: those who received standardized management (n=352) and those who did not (n=463). After propensity score-matching, we compared characteristics and perioperative results between the two groups (n=234 in each group) by univariate analysis. The factors affecting postoperative drainage time and re-admission within 30 days after operation (because of pleural complications) were evaluated via multivariate analysis. Standardized management was as follows: (I) intraoperatively, any dense fissures were left untreated to avoid postoperative air leakage. A fissureless or unidirectional dissection technique served as an alternative; pulmonary vessels and bronchi were divided at the hilum in patients with dense fissures. (II) The chest drain was removed when air leakage ceased, regardless of the fluid volume or surgeon's preference. Results: The standardized management group evidenced superior results in terms of operative time (P<0.0001) and postoperative drainage time (P<0.0001). There were no significant differences in the remaining perioperative parameters. Moreover, standardized management significantly reduced postoperative drainage time, as revealed by multivariate analysis [estimated regression coefficient: -0.47; 95% confidence interval (CI): -0.78 to -0.16; P=0.003]. Moreover, standardized management did not significantly increase re-admission (because of pleural complications) [odds ratio (OR) =1.76; 95% CI: 0.557 to 5.58; P=0.34]. Conclusions: Standardized intra- and peri-operative management significantly reduced the postoperative drainage time after major thoracoscopic pulmonary resections, without increasing re-admissions within 30 days among patients with pleural complications caused by insufficient drainage. Surgeons must master a fissureless or a unidirectional dissection technique, avoid dissection of fused fissures, and apply standardized perioperative drainage management.

Effect of preoperative inspiratory muscle training on postoperative outcomes in patients undergoing cardiac surgery: A systematic review and meta-analysis.

BACKGROUND: Cardiovascular disease is the most prevalent disease worldwide and places a great burden on the health and economic welfare of patients. Cardiac surgery is an important way to treat cardiovascular disease, but it can prolong mechanical ventilation time, intensive care unit (ICU) stay, and postoperative hospitalization for patients. Previous studies have demonstrated that preoperative inspiratory muscle training could decrease the incidence of postoperative pulmonary complications. AIM: To explore the effect of preoperative inspiratory muscle training on mechanical ventilation time, length of ICU stay, and duration of postoperative hospitalization after cardiac surgery. METHODS: A literature search of PubMed, Web of Science, Cochrane Library, EMBASE, China National Knowledge Infrastructure, WanFang, and the China Science and Technology journal VIP database was performed on April 13, 2022. The data was independently extracted by two authors. The inclusion criteria were: (1) Randomized controlled trial; (2) Accessible as a full paper; (3) Patients who received cardiac surgery; (4) Preoperative inspiratory muscle training was implemented in these patients; (5) The study reported at least one of the following: Mechanical ventilation time, length of ICU stay, and/or duration of postoperative hospitalization; and (6) In English language. RESULTS: We analyzed six randomized controlled trials with a total of 925 participants. The pooled mean difference of mechanical ventilation time was -0.45 h [95% confidence interval (CI): -1.59-0.69], which was not statistically significant between the intervention group and the control group. The pooled mean difference of length of ICU stay was 0.44 h (95%CI: -0.58-1.45). The pooled mean difference of postoperative hospitalization was -1.77 d in the intervention group vs the control group [95%CI: -2.41-(-1.12)]. CONCLUSION: Preoperative inspiratory muscle training may decrease the duration of postoperative hospitalization for patients undergoing cardiac surgery. More high-quality studies are needed to confirm our conclusion.

[Impact of the Nursing Personnel Strengthening Act on minimally invasive surgery exemplified by right-sided hemicolectomy from an economic perspective]. / Auswirkungen des Pflegepersonalstärkungsgesetzes auf die minimal-invasive Chirurgie am Beispiel der Hemikolektomie rechts aus ökonomischer Perspektive.

BACKGROUND: In the past, a reduced length of postoperative hospital stay was considered a sufficient trade-off to refinance the additional costs associated with minimally invasive surgery; however, with the implementation of the Nursing Personnel Strengthening Act and disincorporation of nursing costs, this argumentation needs to be fundamentally reevaluated. METHOD: Using right-sided hemicolectomy as an example, a retrospective case analysis was conducted. Cost reductions associated with the length of hospital stay were compared before and after the introduction of the revised German diagnosis-related groups (aG-DRG) and offset against the increased material and personnel costs. RESULTS: Among the analyzed cases, the utilization of minimally invasive surgical techniques led to a substantial cost reduction per case compared to conventional surgical treatment. After the introduction of the aG-DRGs the financial benefits of a shortened hospital stay are greatly diminished and cannot be used to refinance the expenses necessary to perform minimally invasive surgery. From a strictly economical perspective, there is a strong incentive to only perform open surgical procedures. CONCLUSION: Disincorporation of nursing costs has destabilized the fragile concept of indirect refinancing of advanced operative techniques by the financial incentives associated with a shorter hospital stay. In order to comply with statutory regulations to implicate a performance-based funding, there is an urgent necessity to adjust the grouping algorithms for minimally invasive surgical procedures to the corresponding flat rates.

Postoperative hypocalcemia: assessment timing.

180 total thyroidectomy case studies performed by the same operator in the years 2006-2010, all done with sutureless technique (Ligasure precise(®)). The monitoring of patients involved a dose of serum calcium on the 1st, 2nd, 3rd and seventh post-operative, before the ambulatory monitoring of the patient. Treatment of post-operative thyroidectomy also includes the administration from the first day of post-surgery, of 2 g/day of calcium (calcium lactate gluconate 2940 mg, calcium carbonate 300 mg). Hypocalcemia was observed in 27 cases (15%) of which 23/180 (12.8%) were transitional and 4/180 (2.2%) were permanent. The average postoperative hospitalization was 2.5 days with a minimum of 30 h. The peak of hypocalcemia was of 11 patients on the first postoperative day (40.7%) in 6 patients on the second postoperative day (22.2%), in 8 patients on the third postoperative day (29.6%), in 1 patient on the fourth postoperative day (3.7%) and in another one on the fifth postoperative day (3.7%). The second postoperative day is crucial for the determination of early discharge (24-30 h). When the surgeon identifies and manages to preserve at least 3 parathyroid glands during surgery, the risk of hypocalcemia together with evaluations of serum calcium on the first and second post-operative day, eliminates the hypocalcemic risk.