Outcomes of Prolonged Open Abdomen in Children.

INTRODUCTION: We sought to better characterize outcomes in pediatric patients requiring open abdomen for instability with ongoing resuscitation, second look surgery, or left in discontinuity or congenital or acquired loss of domain that may lead to prolonged open abdomen (POA) or difficulties in successful abdominal wall closure. METHODS: We performed a single-institution retrospective review of patients aged less or equal to 18 years who presented to our institution from 2015 to 2022. We defined POA as requiring three or more surgeries prior to abdominal wall closure. Descriptive statistics were performed using median and interquartile range. RESULTS: Median age was 15 years (interquartile range 0-6 years), 46% female, and 69% White. Survival rate was 93% for the entire cohort. The most common indication for open abdomen was second look/discontinuity 22/41 (54%). The most common temporary abdominal wall closure was wound vac (43%). Fifty eight percent patients achieved primary tissue closure, the remaining required mesh. Of the 42 patients, 25 required POA. They had increasing rate of secondary infections at 56% compared to 44% (P = 0.17). The groups were further divided into indications for open abdomen including ongoing resuscitation, second look/discontinuity, and loss of domain with similar outcomes. CONCLUSIONS: In the largest series of long-term outcomes in pediatric patients with an open abdomen, we found that a majority of children were able to be primarily closed without mesh despite the number of surgeries required. Further studies require a protocolized approach to improve the long-term outcomes of these patients.

Quadratus lumborum block versus transversus abdominis plane block for inguinal hernia repair: A systematic review and meta-analysis with trial sequential analysis.

INTRODUCTION: Postoperative pain management is crucial for patient recovery with Quadratus Lumborum Block (QLB) and Transversus Abdominis Plane Block (TAPB) emerging as potential techniques. We aimed to compare the analgesic efficacy of QLB and TAPB in patients undergoing inguinal hernia repair. METHODS: We performed a systematic review of Cochrane, EMBASE, and MEDLINE databases to identify randomized controlled trials comparing QLB and TAPB in patients undergoing inguinal hernia repair. Outcomes included postoperative pain and opioid consumption. Statistical analysis was performed using RevMan 5.4. The review protocol was registered at PROSPERO (CRD42023445513). RESULTS: We included five RCTs encompassing 255 patients. QLB was associated with a significant decrease in postoperative pain (MD -0.45; 95% CI -0.75 to -0.14; and p = 0.004; I2  = 94%). However, we found no difference in 24-h opioid consumption between QLB and TAPB groups. CONCLUSION: QLB may offer superior pain reduction. However, its effect on opioid consumption remains unclear.

Fluid balance in pediatric postoperative liver transplant recipients.

BACKGROUND: Positive fluid balance (FB) is associated with poor outcomes in critically ill children but has not been studied in pediatric liver transplant (LT) recipients. Our goal is to investigate the relationship between postoperative FB and outcomes in pediatric LT recipients. METHODS: We performed a retrospective cohort study of first-time pediatric LT recipients at a quaternary care children's hospital. Patients were stratified into three groups based on their FB in the first 72 h postoperatively: <10%, 10-20%, and > 20%. Outcomes were pediatric intensive care unit (PICU) and hospital length of stay, ventilator-free days (VFD) at 28 days, day 3 severe acute kidney injury, and postoperative complications. Multivariate analyses were adjusted for age, preoperative admission status, and Pediatric Risk of Mortality (PRISM)-III score. RESULTS: We included 129 patients with median PRISM-III score of 9 (interquartile range, IQR 7-15) and calculated Pediatric End-stage Liver Disease score of 15 (IQR 2-23). A total of 37 patients (28.7%) had 10-20% FB, and 26 (20.2%) had >20% FB. Greater than 20% FB was associated with an increased likelihood of an additional PICU day (adjusted incident rate ratio [aIRR] 1.62, 95% CI: 1.18-2.24), an additional hospital day (aIRR 1.39, 95% CI: 1.10-1.77), and lower likelihood of a VFD at 28 days (aIRR 0.85, 95% CI: 0.74-0.97). There were no differences between groups in the likelihood of postoperative complications. CONCLUSIONS: In pediatric LT recipients, >20% FB at 72 h postoperatively is associated with increased morbidities, independent of age and severity of illness. Additional studies are needed to explore the impact of fluid management strategies on outcomes.

Changes in Management at the Postoperative Visit After In-Office Wide Awake Local Anesthetic No Tourniquet Carpal Tunnel Release.

PURPOSE: Patients are commonly seen for two postoperative visits following carpal tunnel release (CTR), the first visit being at 1-2 weeks and the second at approximately 6 weeks. Our study aimed to determine if these visits led to changes in postoperative medical management. METHODS: A retrospective review was conducted of 748 procedures performed in an in-office procedure room under wide awake local anesthetic no tourniquet between August 2020 and December 2022. Charts were reviewed for changes in management related to the patient's CTR. Management changes involving a separate diagnosis or solely an additional follow-up visit were classified as unrelated to postoperative CTR care. RESULTS: A total of 730 patients returned for follow-up. There were 100 patients (13.7 %) who had a CTR-related change in management at the first postoperative visit. Most management changes at this timepoint were due to superficial surgical site infection. There were 29 patients (4.0 %) who had a CTR-related change in management at their second postoperative visit, most commonly a referral to therapy for stiffness or hypersensitivity. CONCLUSIONS: While postoperative visits for CTR may have intangible benefits, changes in CTR-related care occur only in 17.7% of patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Utility of Routine Postoperative Radiographs in the Asymptomatic Total Hip Arthroplasty Patient.

BACKGROUND: Total hip arthroplasty (THA) patients often receive routine radiographs in the year following their index surgery. This study sought to investigate the clinical and economic value of obtaining routine postoperative hip radiographs for asymptomatic patients following primary elective THA. METHODS: A retrospective cohort study of consecutive patients who underwent primary elective THA from 2016 to 2019 was conducted. Patients undergoing nonelective or revision THA, radiographic follow-up <10 months, and patients aged <18 years were excluded. All radiographs were reviewed for abnormalities in the first postoperative year by an arthroplasty fellowship-trained orthopaedic surgeon, blinded to the symptoms of the patient. RESULTS: Of the 327 patients (351 hips) included, 57.2% were women and 68.2% were White, with an average age of 65 years (range, 22-97 years) and average body mass index of 29.1 kg/m2 (range, 16.2-49.8 kg/m2). Only four (0.4%) radiographic series revealed abnormalities with the potential to alter postoperative management. One patient experienced a change in management directly related to their abnormal finding (closed reduction for dislocation at 10.2 months postoperatively). The remaining three abnormal radiographic findings included femoral stem subsidence, progressive radiolucencies around an acetabular component, and cement mantle fracture. The average cost for each radiographic series was $155.27, resulting in total direct charges of $167,691.60. CONCLUSION: Routine postoperative radiographs may be of limited utility in the asymptomatic patient in the first year following elective primary THA. Consideration should be given to limit postoperative radiographs following standard elective THA, while reserving postoperative radiographic evaluation for patients who are symptomatic. LEVEL OF EVIDENCE: Level III.

Randomized Controlled Trial Comparing Early Mobilization vs Six Weeks of Immobilization in a Walking Cast Following Total Ankle Replacement.

Rehabilitation for patients after total ankle replacement traditionally involves weeks of immobilization in a plaster cast followed by progressive mobilization. In a small randomized trial, we compared teh outcomes of patients who received a 3-component cementless, unconstrained, mobile-bearing prosthesis and were initially immobilised in a plaster cast for 6 weeks to thoese who received the same prosthesis but were allowed to mobilise early. Gait, clinical, patient-reported, and radiologic outcomes were measured. The study included 20 patients, 10 in the plaster cast group and 10 in the early mobilization group, and the demographics of the groups did not differ significantly. All patients were followed-up for 24 months. There were no significant differences between the 2 groups 2 years after surgery in ankle dorsiflexion, spatiotemporal gait characteristics, American Orthopaedic Foot and Ankle Society ankle-hindfoot scores, Timed Up and Go Test times, WOMAC (pain, stiffness, function) scores, SF-36 (quality-of-life) scores, or patient satisfaction (pain relief, daily-living, recreational activities, and overall) (all p > .05). Bone mineral density decrease of the medial malleolus and increase at middle tibia, calculated with DEXA scans, was significantly better in early mobilization than plaster cast group at one and 2 years postoperatively, but this was also the case preoperatively. The lack of differences in outcomes suggests that early ankle mobilization may be a safe and reliable method to enhance recovery following ankle arthroplasty with a 3-component cementless, unconstrained, mobile-bearing prosthesis. Compared to traditional plaster casting, patients who are engaged in early mobilization after arthroplasty may enjoy similar functional, mobility, quality-of-life, pain relief, activity level, and satisfaction outcomes.

Diagnosis and treatment of traumatic duodenal rupture in children.

BACKGROUND: The purpose of this study was to investigate the diagnosis and treatment experience of traumatic duodenal ruptures in children. METHODS: Clinical data were collected from four children suffering from a traumatic duodenal rupture who were admitted to and treated by our hospital from January 2012 to December 2020. The early diagnosis and treatment, surgical plan, postoperative management, complications, and prognosis of each child were analyzed. The key points and difficulties of the diagnosis and treatment for this type of injury are summarized. RESULTS: One child had an extreme infection caused by drug-resistant bacteria, which resulted in severe complications, including wound infection, dehiscence, and an intestinal fistula. One child developed an anastomotic stenosis after the duodenostomy, which improved following an endoscopic balloon dilatation. The other two children had no relevant complications after their operations. All four patients were cured and discharged from hospital. The average hospital stay was 48.25 ± 26.89 days. The follow-up period was 0.5 to 1 year. No other complications occurred, and all children had a positive prognosis. CONCLUSIONS: The early identification of a duodenal rupture is essential, and surgical exploration should be carried out proactively. The principles of damage-control surgery should be followed as much as possible during the operation. Multidisciplinary cooperation and management are both important to reduce the occurrence of postoperative complications and improve cure rates.

Reappraisal of liver transplantation for erythropoietic protoporphyria: A deadly combination of disease recurrence and biliary complication.

BACKGROUND: Erythropoietic protoporphyria (EPP) is a rare inherited disorder that causes the accumulation of protoporphyrin in the erythrocytes, skin, and liver. Severe protoporphyric hepatopathy results in liver failure, requiring both liver and bone marrow transplantation as a life-saving procedure and to correct the underlying enzymatic defect, respectively. CASE PRESENTATION: We report a 20-year-old man who underwent split liver transplantation using a right trisegment and caudate lobe graft for EPP-induced liver failure, but succumbed to a deadly combination of early relapse of EPP and subsequent, intractable, late-onset bile leakage from the cut surface of segment 4. EPP recurrence most likely created a high-risk situation for bile leakage from the non-communicating bile ducts of segment 4; therefore, this case shed light on the potential relationship between EPP recurrence and biliary complications. CONCLUSION: Physicians should recognize the potentially rapid and life-threatening progression of protoporphyric hepatopathy that leads to liver failure. For young patients with EPP, LT and sequential BMT should thoroughly be considered by a multidisciplinary team as soon as hepatic reserve deterioration becomes evident. Split liver transplantation should preferably be avoided and appropriate post-transplant management is critical before protoporphyrin depositions to the bile duct and hepatocyte causes irreversible damage to the liver graft.

Early postoperative endoscopic evaluation of rectal anastomoses: a prospective cross-sectional study.

BACKGROUND: Reported incidence of anastomotic leakage (AL) of rectal anastomoses is up to 29% with an overall mortality up to 12%. Nevertheless, there is no uniform evidence-based diagnostic procedure for early detection of AL. The objective of this prospective clinical trial was to demonstrate the diagnostic value of early postoperative flexible endoscopy for rectal anastomosis evaluation. METHODS: Flexible endoscopy between 5 and 8th postoperative day was performed consecutively in 90 asymptomatic patients. Sample size calculation was made using the two-stage Simon design. Diagnostic value was measured by management change after endoscopic evaluation. Anastomoses were categorized according to a new classification. Study is registered in German Clinical Trials Register (DRKS00019217). RESULTS: Of the 90 anastomoses, 59 (65.6%) were unsuspicious. 20 (22.2%) were suspicious with partial fibrin plaques (n = 15), intramural hematoma and/or local blood coagulum (n = 4) and ischemic area in one. 17 of these anastomoses were treated conservatively under monitoring. In three a further endoscopic re-evaluation was performed and as consequence one patient underwent endoscopic vacuum therapy. 11 (12.2%) AL were detected. Here, two could be treated conservatively under monitoring, four with endoscopic vacuum therapy and five needed revision surgery. No intervention-related adverse events occurred. A change in postoperative management was made in 31 (34.4%) patients what caused a significant improvement of diagnosis of AL (p < 0.001). CONCLUSIONS: Early postoperative endoscopic evaluation of rectal anastomoses is a safe procedure thus allows early detection of AL. Early treatment for suspicious anastomoses or AL could be adapted to avoid severe morbidity and mortality.

Optimal, Early Postoperative Management of Cardiac Transplant and Durable Left Ventricular Assist Recipients.

PURPOSE OF REVIEW: Summarize developments in the early postoperative care of patients undergoing cardiac transplantation or left ventricular assist device implantation. Provide a practical approach with personal insights to highly complex patients at risk for prolonged hospitalization. RECENT FINDINGS: Advancements in technology allow for percutaneous mechanical circulatory support of both the right and left ventricles either isolated or combined via subclavian and neck vessels. Since the adult heart allocation system has been changed to reduce waitlist mortality, the use of temporary mechanical circulatory support has increased. This has influenced preoperative optimization by enabling ambulation and majorly changed postoperative strategy. New doors have been opened for a multidisciplinary approach to facilitate rapid weaning of inotropic medications, limitation of sedation, early liberation from mechanical ventilation, and mobilization. Individualized percutaneous mechanical circulatory support offers new possibilities for the early postoperative management of highly complex patients undergoing cardiac transplantation or durable left ventricular assist device implantation.

Characterization of litigation after tonsillectomy in the United States.

BACKGROUND: Tonsillectomy is a common procedure performed for both adults and children. When unfavorable outcomes occur during perioperative events, patients may seek compensation through medical malpractice or medical negligence litigation. An understanding of these cases can help physicians and involved health care providers avoid risk and improve patient satisfaction. The aims of this study were to identify reasons for litigation after tonsillectomy and to examine outcomes of tonsillectomy-related litigation in the United States. METHODS: All available court decisions associated with medical malpractice and negligence after tonsillectomy in the Westlaw Campus Research legal database were reviewed. The plaintiff' relationship to the patient, patient characteristics, state where the tonsillectomy took place, specialty of the defendant(s), allegations, and adjudicated case outcomes were obtained from case documents and analyzed. RESULTS: Forty-two relevant judicial opinions written between 1986 and 2020 in 24 states were included. Twenty-two (52.4 %) of the cases involved female patients, and 24 (57.1 %) involved pediatric patients. Otolaryngology, anesthesiology, primary care, emergency medicine, orthodontics, and pharmacy were the disciplines involved in the negligence claims. Claims involved postoperative management in 18 (42.9 %) of the cases and intraoperative misadventure in 17 (40.5 %) of the cases. Six (14.3 %) of the 42 patients experienced an anesthesia complication, and 11 (26.2 %) experienced a surgical complication. Eleven (26.2 %) patients experienced postoperative bleeding. All cases involved postoperative concerns, and death occurred in 14 (33.3 %) of the patients. Overall, 21 (45.7 %) of the rulings were for the defendant. CONCLUSIONS: Postoperative management and intraoperative misadventure are commonly cited reasons for legal action after tonsillectomy procedures in the United States. All litigation surrounding tonsillectomy arose if concerns were present postoperatively. Thorough communication and attentive postoperative management are critical in order to avoid complications and patient injury, including death, associated with tonsillectomy.

Postoperative management of Zenker's diverticulum: Results of the American Bronchoesophagological Association survey.

INTRODUCTION: Although treatment of Zenker's diverticulum (ZD) is commonly performed by otolaryngologists using a variety of surgical techniques, there is little published data on the postoperative management of patients. We sought to determine practice patterns among members of the American Bronchoesophagological Association (ABEA) after surgery for ZD. METHODS: An online questionnaire was designed via JotForm™ and subsequently sent to active members of the ABEA. Responses were analyzed using descriptive statistics. RESULTS: Twenty-three members (6.6 %) completed the survey. Most (73.9 %) were fellowship trained in laryngology and reported performing >5 procedures per year. Most laryngologists reported employing multiple techniques including transcervical (TC) (73.9 %), endoscopic stapling (ES) (65.2 %), endoscopic CO2 laser (EL) (56.5 %), and endoscopic harmonic scalpel (EH) (4.3 %). Postoperatively, 52.3 % of respondents placed patients in 23-hour observation after TC, 66.7 % after ES, 69.2 % after EL, and 100 % after EH. 47.1 % of respondents used standard overnight admission after TC, as compared to 13.3 % after ES, 23.1 % after EL and 0 % after EH. Postoperative esophagography was utilized by 70.6 % of respondents after TC, 20 % after ES, 38.5 % after EL, and 100 % after EH. A peroral diet was started postoperatively on the day of surgery by 26.7 % respondents after ES but not after any of the other techniques. CONCLUSION: Most laryngology trained respondents employ multiple techniques for the treatment of ZD including at least 1 endoscopic technique. Respondents were more likely to hospitalize patients after a transcervical than endoscopic approach. Postoperative esophagography was utilized in most patients after TC, but not after ES or EL. Most respondents admit patients for 23-hour observation and start a peroral diet on postoperative day 1 regardless of technique.

Onset of Adverse Abdominal Events Due to Intestinal Ischemia-Reperfusion Injury after Aortic Cross-Clamping Is Associated with Elevated HSP70 Serum Levels in the Early Postoperative Phase.

Tissue injury of the viscera during open thoracoabdominal aortic (TAA) reconstructions has been reported as the aftermath of the ischemia-reperfusion mechanism following supracoeliac aortic cross-clamping. Abdominal complications after open aortic reconstructions, although rare through the intraoperative implementation of selective visceral artery blood perfusion, are associated with high rates of reinterventions and a poor prognosis. Recent animal experiments demonstrated that provoking mesenteric ischemia in rats induces the leukocyte-mediated transcription of heat-shock protein 70 (HSP70), a chaperone belonging to the danger-associated molecular pattern proteins (DAMPs). Translating these findings clinically, we investigated the serum levels of HSP70 in patients undergoing open aortic reconstructions with supracoeliac clamping. We postoperatively observed a relevant induction of HSP70, which remained significantly elevated in cases of postoperative abdominal complications (paralytic ileus, abdominal compartment syndrome, and visceral malperfusion). The receiver-operator curve analysis revealed the reliable prognostic accuracy of HSP70 as a biomarker for these complications as soon as 12 h post-operation (AUC 0.908, sensitivity 88.9%, specificity 83.3%). In conclusion, measuring HSP70 serum levels in the early postoperative phase may serve as a further adjutant in the diagnostic decision making for both the vascular surgeon and intensivist for the timely detection and management of abdominal complications following open TAA surgery.

The frequency of postoperative BNP measurement and intervention threshold of BNP concentration in pediatric cardiac intensive care unit: a prospective multicenter observational study.

PURPOSE: The purpose of this study is to investigate the current status of postoperative BNP measurement in the pediatric cardiac intensive care unit (PCICU). METHODS: This was a prospective multicenter observational study. Children under 15 years old who underwent pediatric cardiac surgery were included. Postoperatively, all BNP measurement was collected in PCICU. We checked whether each BNP measurement was used for the decision-making of intervention or not. We divided the BNP measurements into 4 groups: group A 0-299 pg/ml (reference), group B 300-999 pg/ml, group C 1000-1999 pg/ml, group D ≧ 2000 pg/ml. We performed logistic regression analysis to compare the intervention ratio between group A and B, C, D. We also did multiple comparison analyses to compare the intervention ratio in each group. RESULTS: Thirty-nine (15.8%) measurements were used as a criterion to intervene in all BNP measurements. There was no protocol for the measurement of BNP in all institutions. The number of BNP measurements in each group is as follows: group A 113 (45.9%), group B 81 (32.9%), group C 45 (18.3%), group D 7 (2.8%). The intervention ratio in each group was 6.2% (group A), 8.6% (group B), 44.4% (group C), and 71.4% (group D). The intervention ratio of group C and D were significantly higher than group A: (Odds ratio (95%CI): 12.1(4.8-33.9), p < 0.0001, 25.2(5.2-146.2), p < 0.0001). The result of multiple comparisons is similar to logistic regression analysis. CONCLUSION: High BNP concentration, especially more than 1000 pg/ml, was more often intervened upon compared to that of less than 1000 pg/ml.

Outpatient vagus nerve stimulation surgery in patients with drug-resistant epilepsy with severe intellectual disability.

PURPOSE: Vagus nerve stimulation (VNS) implantation is increasingly proposed in outpatient procedure. Some epilepsy syndromes are associated with severe neurodevelopmental disabilities (intellectual disability, autism) and often motor or sensory handicaps, making ambulatory surgery more complex. METHODS: We prospectively assessed the feasibility and safety of outpatient VNS implantation in 26 adult patients with drug-resistant epilepsy with severe intellectual disability between December 2017 and October 2020. RESULTS: The male-to-female ratio was 0.9 and the mean age on surgery day was 23.1 years. Seventeen patients (65.4%) suffered from epileptic encephalopathy, 7 (26.9%) from cryptogenic or genetic generalized epilepsy, and 2 (7.7%) from severe multifocal epilepsy. Postoperatively, all patients were discharged the day of surgery. No patient was admitted to a hospital or have consulted within one month due to postoperative complications. There was no surgery-related complication during patients' follow-up. CONCLUSION: Our study highlights the safety and feasibility of VNS surgery in an outpatient setting for patients with severe intellectual disability. We report detailed protocol and preoperative checklist to optimize outpatient VNS surgery in these not able-bodied patients. Severe disabilities or epilepsy-associated handicaps should not be an exclusion criterion when considering ambulatory VNS implantation.

Risk factors for Takotsubo syndrome following cardiac surgery: A case-control study.

OBJECTIVE: Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis. METHODS: We retrospectively studied 5773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis. RESULTS: Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared with 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR) 10.5; 95% confidence interval (CI), 2.6-42.5; p = 0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95% CI, 1.0-10.7; p = 0.05) and dobutamine (OR, 4.8; 95% CI, 1.72-13.3; p = 0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95% CI, 0.06-0.73; p = 0.01). CONCLUSION: Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

Generalized convulsive status epilepticus after retrograde type A aortic dissection surgery.

INTRODUCTION: Generalized convulsive status epilepticus is defined as a generalized and convulsive seizure with 5 minutes or more of continuous clinical and/or electrographic seizure activity or recurrent seizure activity without recovery between seizures. For the first time, we present a case with retrograde type A aortic dissection after endovascular repairment and received thoracotomy intensely. CASE REPORT: The patient experienced frequent generalized seizures in the immediate postoperative period, and status epilepticus was considered for his medical history, clinic symptoms and related examinations. DISCUSSION AND CONCLUSION: Generalized convulsive status epilepticus should be alert for avoiding delay in the rehabilitation particularly after aortic dissection surgery. Under the good condition of ventilation, combining morphine with midazolam or diazepam can more effectively relieve the symptoms.

Implementation of a standardized voiding management protocol to reduce unnecessary re-catheterization - A quality improvement project.

OBJECTIVE: To design and implement a standardized postoperative voiding management protocol that accurately identifies patients with urinary retention and reduces unnecessary re-catheterization. METHODS: A postoperative voiding management protocol was designed and implemented in patients undergoing major, inpatient, non-radical abdominal surgery with a gynecologic oncologist. No patients had epidural catheters. The implemented quality improvement (QI) protocol included: 1) Foley removal at six hours postoperatively; 2) universal bladder scan after the first void; and 3) limiting re-catheterization to patients with bladder scan volumes >150 ml. A total of 96 patients post-protocol implementation were compared to 52 patients pre-protocol. Along with baseline demographic data and timing of catheter removal, we recorded the presence or absence of urinary retention and/or unnecessary re-catheterization and postoperative urinary tract infection rates. Fisher's exact test and student's t-tests were performed for comparisons. RESULTS: The overall rate of postoperative urinary retention was 21.6% (32/148). The new voiding management protocol reduced the rate of unnecessary re-catheterization by 90% (13.5% vs 2.1%, p = 0.01), without overlooking true urinary retention (23.1% vs 20.8%, p = 0.83). Additionally, there was a significant increase in hospital-defined early discharge prior to 11:00 AM (4.0% vs 22.0%, p = 0.022). There was no difference in the postoperative urinary tract infection rate between the groups (p = 1.00). Risk factors associated with urinary retention included older age (p < 0.01), use of medications with anticholinergic properties (p < 0.01), and preexisting urinary dysfunction (p < 0.01). CONCLUSIONS: Implementation of this new voiding management protocol reduced unnecessary re-catheterization, captured and treated true urinary retention, and facilitated early hospital discharge.

Evaluation of Pain Management after Surgery: An Observational Study.

Background and Objectives: Choosing a pain management strategy is essential for improving recovery after surgery. Effective pain management reduces the stress response, facilitates mobilization, and improves the quality of the postoperative period. The aim of the study was to assess the effectiveness of pain management in patients after surgery. Materials and Methods: The study included 216 patients operated on in the following surgical wards: the Department of Cardiosurgery and the Department of General and Endocrine Surgery. Patients were hospitalized on average for 6 ± 4.5 days. Patients were randomly selected for the study using a questionnaire technique with a numerical rating scale. Results: Immediately after surgery, pre-emptive analgesia, multimodal analgesia, and analgosedation were used significantly more frequently than other methods (p < 0.001). In the subsequent postoperative days, the method of administering drugs on demand was used most often. Patients with confirmed complications during postoperative wound healing required significantly more frequent use of drugs from Steps 2 and 3 of the World Health Organization (WHO) analgesic ladder compared with patients without complications. Conclusion: The mode of patient admission for surgery significantly affected the level of pain perception. Different pain management methods were used and not every method was effective.

The surgical treatment strategies for thoracolumbar spine fractures with ankylosing spondylitis: a case report.

BACKGROUND: Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects spine and paraspinal soft tissue. Ankylosing spondylitis is one of the causes of osteoporosis and patients with ankylosing spondylitis tend to have spinal fractures due to limited mobility and osteoporosis. In recent years, due to the increase in the number of patients with AS, patients with AS and thoracolumbar spine fractures have gradually increased. In the past 1 year, we have treated 3 cases of AS with thoracolumbar spine fractures via simple posterior internal fixation and this paper aims to report its clinic effect. CASE PRESENTATION: All the three patients selected had a history of ankylosing spondylitis for nearly 30 years, and one of them developed a thoracolumbar spine fracture after falling when he walked, and the other two developed a thoracolumbar spine fracture without any reason. They were hospitalized for "low back pain" and were diagnosed as fractures after careful physical examination and imaging examinations such as X-ray, CT, and MRI. After the preoperative preparation was completed, all the three patients underwent surgery with simple posterior internal fixation-reduction of the fracture and pedicle screw fixation via posterior approach. All the implants-pedicle screws and connecting rods-are made of titanium alloy. For postoperative management, we asked all the patients to stay in bed for 3 weeks after the operation, and then slowly move down with the help of crutches. Fracture healing and neurological function recovery were observed postoperatively. All the three patients recovered satisfactorily after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months. CONCLUSIONS: The 3 patients included 2 men and 1 women. All the 3 patients recovered well after surgery, and the follow-up confirmed that the fracture healed successfully after 3 months. One man developed urination dysfunction after operation and recovered to normal 3 months after rehabilitation exercise.