Surgical Outcomes Research

Background Bariatric surgery is an effective treatment to obtain weight loss in severely obese patients. The feasibility and safety of bariatric robotic surgery is the topic of this review. Methods A search was performed on PubMed, Cochrane Central Register of Controlled Trials, BioMed Central, and Web of Science. Results Twenty-two studies were included. Anastomotic leak rate was 8.51% in biliopancreatic diversion. 30-day reoperation rate was 1.14% in Roux-en-Y gastric bypass and 1.16% in sleeve gastrectomy. Major complication rate in Roux-en-Y gastric bypass resulted higher than in sleeve gastrectomy ( 4,26% vs. 1,2%). The mean hospital stay was longer in Roux-en-Y gastric bypass (range 2.6-7.4 days). Conclusions The major limitation of our analysis is due to the small number and the low quality of the studies, the small sample size, heterogeneity of the enrolled patients and the lack of data from metabolic and bariatric outcomes. Despite the use of the robot, the majority of thes...

Introduction: Tibial shaft fractures pose a significant challenge in orthopaedic practice, often necessitating surgical intervention for optimal recovery. The selection of the entry point for intramedullary nailing, particularly between the suprapatellar and infrapatellar approaches, remains a debated aspect in fracture management. While both approaches aim to restore stability and function, their nuances influence outcomes and patient experiences. This study aims to comprehensively compare the suprapatellar and infrapatellar approaches, analyzing surgical techniques, complications, and functional outcomes to inform clinical decision-making.

Methodology: A retrospective comparative analysis was conducted on patients undergoing intramedullary nailing for tibial shaft fractures, comparing outcomes between the suprapatellar and infrapatellar approaches. Data collection included patient demographics, fracture characteristics, intraoperative details, and postoperative outcomes. Statistical analysis was performed using appropriate tests, with a significance level set at p < 0.05.

Result: Operative time was longer in the infrapatellar group (137.8 minutes) compared to the suprapatellar group (114.4 minutes). The mean radiation dose was higher in the infrapatellar group (74.3 cGY/cm2) and lower in the suprapatellar group (48.5 cGY/cm2). Postoperative outcomes showed a mean Lysholm score of 74 in the infrapatellar group and 90 in the suprapatellar group. one case of infection and one case of malunion were reported in the infrapatellar group, while the suprapatellar group had one infection case but no instances of non-union or malunion.

Conclusion: This study provides valuable insights into the surgical and clinical outcomes of the suprapatellar and infrapatellar approaches for tibial shaft fractures. While both techniques offer viable options, the suprapatellar approach may offer advantages in terms of operative efficiency and functional recovery.

In recent years, the management of synchronous colorectal liver metastasis has changed significantly. Alternative surgical strategies to the classical colorectal-first approach have been proposed. These include the liver-first and combined resections approaches. The objectives of this review were to compare the short- and long-term outcomes for all three approaches. A systematic review of comparative studies was performed. Evaluated endpoints included surgical outcomes (5-year overall survival, 30-day mortality, and post-operative complications). Pair-wise and network meta-analysis (NMA) were performed to compare survival outcomes. Eighteen studies were included in this review, reporting on 3,605 patients. NMA and pair-wise meta-analysis of the 5-year overall survival did not show significant difference between the three surgical approaches: combined versus colorectal-first, mean odds ratio (OR) 1.02 (95% CI 0.8-1.28, P = 0.93); liver-first versus colorectal-first, mean OR 0.81 (95%...

Wilms’ tumor (WT) is one of the most common childhood
abdominal malignancies. Imaging plays a central role in diagnosis, staging,
and response evaluation and follows up of children with WT. The aim of
this study is to evaluate Computed Tomography (CT)-based image defined
risk factors according to Socie’te’ Internationale d’ Oncologie Pe’diatrique
(SIOP) protocol in predicting surgical outcomes in children with WT.

Background: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. Methods: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. Results: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm 2 versus NNSM, 56.5(±25.7) g/mm 2 , although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm 2 versus NNSM, 83.8(±27.4) g/mm 2 (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. Conclusions: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

Background: Changes in breast sensation after reconstruction are expected. Return of breast sensation after reconstruction and whether nipple-sparing mastectomy offers a substantial benefit in terms of sensation has been inconsistently documented in the literature. We conducted the current study using the pressure-specified sensory device to quantify postoperative breast sensation in patients undergoing nipple-sparing versus non-nipple-sparing mastectomy. Methods: Consecutive adult women who underwent nipple-sparing (NSM) and non-NSM (NNSM) and were at least 18 months postreconstruction were included. Breast measurements were taken in 4 quadrants (upper/lower lateral, upper/lower medial) and nipple. Averaged skin cutaneous thresholds [(UL+LL+UM+LM)/4] and nipple sensation between NSM and NNSM were compared as the primary outcome measure. A generalized estimating equations model was used; univariate and multivariate variable analyses were done when appropriate. Results: Forty-four patients (74 breasts) were examined (53 NNSM vs 21 NSM). The groups were further subdivided into autologous versus implant-based reconstruction. Averaged cutaneous skin thresholds for quadrants were better for the NSM, 51.8(±24.5) g/mm 2 versus NNSM, 56.5(±25.7) g/mm 2 , although this difference was not statistically significant. However, NSM breasts measured higher nipple or nipple area sensitivity, 44.5(±30.8) g/mm 2 versus NNSM, 83.8(±27.4) g/mm 2 (P < 0.001). In a multivariate regression analysis, a predictor of decreased sensation was the number of revision surgeries, especially after third revision. Conclusions: Breast sensation is decreased after reconstruction in both NSM and NNSM, but nipple sensation or nipple area is better preserved in NSM breasts. Number of revision surgeries (>3) was a predictor of decreased sensation.

is dedicated to all health care professionals who consider themselves "Health Care Engineers," and who aspire to improve patient care by the application of systems and processes to the clinical practice of medicine. I would like to acknowledge my wife, for providing support, encouragement, and editorial assistance; my children and my grandson for providing the stimulus to persevere; my staff, for helping to carry the load during the years of study; my colleagues for making it feasible for me to pursue this goal; the faculty and students of the Department of Industrial and Management Systems Engineering for accepting me into their ranks; the Department of Veterans Affairs for supporting me during my studies; the University of South Florida College of Medicine for providing me support, time, and collaboration; and the USF Department of Surgery faculty and residents for actively participating in the study design and implementation.

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

Background: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low-and middle-income countries (LMICs). Methods: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. Results: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4e11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2e8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6e1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. Conclusions: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings

The automatic assessment of hippocampus volume is an important tool in the study of several neurodegenerative diseases such as Alzheimer&#39;s disease. Specifically, the measurement of hippocampus subfields properties is of great interest since it can show earlier pathological changes in the brain. However, segmentation of these subfields is very difficult due to their complex structure and for the need of high-resolution magnetic resonance images manually labeled. In this work, we present a novel pipeline for automatic hippocampus subfield segmentation based on a deeply supervised convolutional neural network. Results of the proposed method are shown for two available hippocampus subfield delineation protocols. The method has been compared to other state-of-the-art methods showing improved results in terms of accuracy and execution time.

Aim: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. Patients and methods: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Results: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P = 0.43) correlating between days to HR from the index procedure showed no specific cutoff point regarding postoperative complications (P = 0.16), Major (Clavien-Dindo score of 3 or more) complications (P = 0.19), Minor (Clavien Dindo 1-2) and no complications (P = 0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P = 0.4).

Background Use of biological or synthetic mesh might improve outcomes of immediate implant-based breast reconstruction-breast reconstruction with implants or expanders at the time of mastectomy-but there is a lack of high-quality evidence to support the safety or effectiveness of the technique. We aimed to establish the short-term safety of immediate implant-based breast reconstruction performed with and without mesh, to inform the feasibility of undertaking a future randomised clinical trial comparing different breast reconstruction techniques. Methods In this prospective, multicentre cohort study, we consecutively recruited women aged 16 years or older who had any type of immediate implant-based breast reconstruction for malignancy or risk reduction, with any technique, at 81 participating breast and plastic surgical units in the UK. Data about patient demographics and operative, oncological, and complication details were collected before and after surgery. Outcomes of interest were implant loss (defined as unplanned removal of the expander or implant), infection requiring treatment with antibiotics or surgery, unplanned return to theatre, and unplanned re-admission to hospital for complications of reconstructive surgery, up to 3 months after reconstruction and assessed by clinical review or patient self-report. Follow-up is complete. The study is registered with the ISRCTN Registry, number ISRCTN37664281.

Background: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low-and middle-income countries (LMICs). Methods: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. Results: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4e11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2e8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6e1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. Conclusions: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings

Surgical grand rounds at a university hospital and the application of "publication presentation index" to evaluate outcomes-Should we now finally move towards publish and flourish? Author contribution AJFwriting, editing, final approval. RAconcept, editing, final approval.

Duodenal ulcer perforation is one of the most commonly encountered condition in emergency surgery. Laparoscopic repair of the perforation has been reported in many cases since the first laparoscopic repair of a duodenal perforation in the year 1990 by Mouret et al. Aim and objectives were to study the clinical outcomes of laparoscopic repair of duodenal perforation in terms of duration of surgery, post operative pain, initiation of oral feeds, surgical site infection and duration of hospital stay. Over a 2 year period, 2018-2020, 20 patients with a presumptive diagnosis of perforated duodenal ulcers were considered for laparoscopic closure. Primary closure of the perforation was done with intracorporeal suturing followed by omental patch repair. The mean age was 38.75±8.53 years, mean duration of surgery was 97.80±7.89 minutes. The mean number of analgesic injection was 2.90±0.72. The mean duration of initiation of oral feeds was 3.20±0.41 days. The mean duration of removal of drain...

Colorectal anastomosis is defined as a surgical procedure in which the colon is attached to the remainder of the rectum after most or some part of it was removed during an intervention. A straight colorectal anastomosis implies a direct attachment, while a J-pouch colorectal anastomosis implies a previous creation of a reservoir, or “pouch” out of bowel material. The problem of colorectal anastomosis safety and outcome is among the most important and persistent issues in colorectal surgery, mainly due to the anastomotic leakage, a threatening and dangerous complication, with an incidence of up to 20% or even more in case of surgical oncology. Various prediction models and anastomosis testing techniques have been described in order to prevent or identify early any possible imperfection of the anastomosis, each with pros and cons. The measures generally used to increase the safety and reliability of the colorectal anastomosis are to evaluate the blood supply of the tissues anastomosed...

Background: Perforated peptic ulcer is a common surgical emergency. The classic treatment is the mid-line laparotomy. However, laparoscopic treatment has been shown to be reliable. Few studies have evaluated its overall utility. The aim of this study is to assess the efficacy of laparoscopic repair of perforated duodenal ulcer. Patients and Methods: This study included 50 patients presented by perforated peptic ulcer between July 2009 and August 2014. They were submitted to laparoscopic omental patch repair with thorough peritoneal wash. Patients' demographics, diagnostic techniques, management and outcome were evaluated. Results: The mean age was 38.6 years with male to female ratio being 1.6:1. The perforation was diagnosed by plain X-ray abdomen in erect position in 43 patients and by abdominal CT scan in 7 patients. The laparoscopic repair of the perforation was successful in 48 patients while in 2 patients mid-line laparotomy was needed for proper control of the severe intra-abdominal sepsis. Post-operatively, all patients tolerated soft diet on the 3 rd post-operative day and full diet on the 4 th post-operative day. The mean duration of hospital stay was 4.5 days. Two patients developed post-operative intra-abdominal collection that was treated by ultrasound guided drainage, three patients developed umbilical port site wound infection while only two patients developed leakage, one of them reoperated after failed conservative surgery. No mortality was encountered in the study. Conclusion: Laparoscopic repair of perforated peptic ulcer is a safe and reliable technique with accepted morbidity and mortality rates with all the advantages of the minimally invasive surgery.

Complete mesocolic excision (CME) is a new concept of right hemicolectomy for colon cancer (CC) set up to improve oncological outcomes and based on three main points: dissection in the embryological plane, central vascular ligation (CVL) and resection of a sufficient length of bowel. During this last decade, many doubts and questions have been arised about safety and efficacy of CME. We conducted a systematic review of the literature to investigate the safety, quality and survival outcomes of this procedure. Literature search resulted in 659 articles found and after the selection process 21 studies properly fulfilling inclusion and exclusion criteria were included. The total number of collected patients was 7,402 (mean age 65.42 years, 51.27% men). The weighted mean number of lymph nodes retrieved was 27.45 and the mean number of metastatic nodes was 1.34. Surgical complication and overall operative mortality rate were 5.5% and 0.5% respectively. Five-year overall survival (OS) and disease-free survival (DFS) rates were 84.3% and 82.8%. Available data from literature have several limitations mostly including non-homogeneous and incomplete reports together with no evidence from randomized control trial (RCT) studies. Therefore, to date, the quality of evidence is low and does not consistently support the superiority of CME over the standard right hemicolectomy, despite a reported trend to improved survival with comparable operative morbidity and mortality. More reliable data from large sample size RCTs are needed before CME can be recommended as the standard of care for right CC.

AimAt presentation, 15–20% of patients with rectal cancer already have synchronous liver metastases. The aim of this study was to determine the surgical and survival outcomes in patients with advanced rectal cancer who underwent combined pelvic exenteration and liver (oligometastatic) resection.MethodData from 20 international institutions that performed simultaneous pelvic exenteration and liver resection between 2007 and 2017 were accumulated. Primarily, we examined perioperative outcomes, morbidity and mortality. We also assessed the impact that margin status had on survival.ResultsOf 128 patients, 72 (56.2%) were men with a median age of 60 years [interquartile range (IQR) 15 years]. The median size of the liver oligometastatic deposits was 2 cm (IQR 1.8 cm). The median duration of surgery was 406 min (IQR 240 min), with a median blood loss of 1090 ml (IQR 2010 ml). A negative resection margin (R0 resection) was achieved in 73.5% of pelvic exenterations and 66.4% of liver resect...

Introduction: The impact of the nasal septum morphology on the severity of obstruction symptoms has not been fully explored. Objective: This study aimed to investigate whether the morphology of the deviated nasal septum assessed by computed tomography may explain nasal obstruction severity. Methods: The study included 386 patients who were referred to the computed tomography examination of the paranasal sinuses. Patient selection criteria were the absence of facial anomalies, facial trauma, nasal surgery, and sinonasal tumors. Computed tomography images were used to estimate deviated nasal septum prevalence, the prevalence of Mladina's seven types of deviated nasal septum, and to measure the deviated nasal septum angle. Nasal obstruction severity was assessed by the nasal obstruction symptom evaluation, NOSE scale. The relationship between NOSE score, deviated nasal septum morphology, and deviated nasal septum angle was performed by a statistical regression model on the reduced sample of 225 patients. Results: The prevalence of deviated nasal septum was 92.7%. Type 7 deviated nasal septum was the most frequent (34.2%) followed by type 5 (26.2%) and type 3 (23.6%). The worst NOSE scores were recorded in the type 2 deviated nasal septum (45.00 ± 28.28). The mean deviated nasal septum angle in patients with nasal obstruction was 8.5 • ± 3.24. NOSE scores were not significantly associated with deviated nasal septum types and angles.

Objectives Outcomes of surgical emergencies are associated with promptness of the appropriate surgical intervention. However, delayed presentation of surgical patients is common in most developing countries. Delays commonly occur due to transfer of patients between facilities. The aim of the present study was to assess the effect of delays in treatment caused by inter-facility transfers of patients presenting with surgical emergencies as measured by objective and subjective parameters. Methods We prospectively collected data on all patients presenting with an acute surgical emergency at Aga Khan University Hospital (AKUH). Information regarding demographics, social class, reason and number of transfers, and distance traveled were collected. Patients were categorized into two groups, those transferred to AKUH from another facility (transferred) and direct arrivals (nontransfers). Differences between presenting physiological parameters, vital statistics, and management were tested between the two groups by the chi square and t tests. Results Ninety-nine patients were included, 49 (49.5 %) patients having been transferred from another facility. The most common reason for transfer was ''lack of satisfactory surgical care.'' There were significant differences in presenting pulse, oxygen saturation, respiratory rate, fluid for resuscitation, glasgow coma scale, and revised trauma score (all p values \0.001) between transferred and nontransferred patients. In 56 patients there was a further delay in admission, and the most common reason was bed availability, followed by financial constraints. Three patients were shifted out of the hospital due to lack of ventilator, and 14 patients left against medical advice due to financial limitations. One patient died. Conclusions Inter-facility transfer of patients with surgical emergencies is common. These patients arrive with deranged physiology which requires complex and prolonged hospital care. Patients who cannot afford treatment are most vulnerable to transfers and delays.

There is urgent need to improve access to safe surgical treatments for patients in low-and middle-income countries (LMICs). However, few data exist to characterise clinical outcomes for this patient population. Methods: Consecutive patients undergoing surgery at a referral hospital in Uganda were prospectively followed between October 2016 and October 2017. The primary outcome was in-hospital, postoperative mortality. Secondary outcomes were in-hospital complications for patients undergoing laparotomy and Caesarean section. Results are presented as n (%) or odds ratios (OR) with 95% confidence intervals. Results: A total of 4 773 patients of mean age 28 years were included; 3 754 were female (79.0%) and 4 259 patients (89.4%) were classified as American Society of Anesthesiologists class I or II. Some 3 501 (73.8%) procedures were performed on an emergency basis. The most frequent procedure was Caesarean section (2 634 patients [55.3%]). There were 93 deaths (2.0%), 49 of which occurred after the day of surgery (59.0%). In multivariable analysis, patients undergoing general (abdominal) surgery were at greatest risk of death (OR 4.34 [2.02-9.30]). Postoperative complications were recorded for 24/412 (5.8%) patients undergoing Caesarean section and 18/107 (16.8%) patients undergoing emergency laparotomy. Infection was the most frequent complication in these patient groups (33/519 patients [6.4%]). Conclusions: This study confirms the feasibility of longitudinal audit of postoperative outcomes in LMICs. Data collected over a one-year period were highly consistent with the findings of a recent seven-day cohort study conducted across Africa.

Aim: Hartmann's procedure is the surgical treatment of choice for perforated acute diverticulitis. Hartmann's reversal (HR) that is performed at a later stage may be challenging. The optimal timing for HR is still a subject for controversy. The aim of this study is to assess whether the timing of HR affects surgical outcome. Patients and methods: A retrospective-cohort multi-center study was conducted, including all patients who underwent HR for acute diverticulitis from January 2004 to June 2015 in 5 medical centers. Patient data included demographics, surgical data and post-operative outcome. Results: One hundred and twenty-two patients were included in the database. Median time from Hartmann's procedure to reversal was 182.7 days, with the majority of patients (76 patients, 62.2%) operated 60 to 180 days from the Hartmann's procedure. Fifty-seven patients (46.7%) had post-operative complications, most commonly wound infections (27 patients, 22.1%). Receiver operating characteristic (ROC) curve and a propensity score match analysis (P = 0.43) correlating between days to HR from the index procedure showed no specific cutoff point regarding postoperative complications (P = 0.16), Major (Clavien-Dindo score of 3 or more) complications (P = 0.19), Minor (Clavien Dindo 1-2) and no complications (P = 0.14). Median length of stay was 10.9 days (range 3-90) and Pearson correlation failed to demonstrate a correlation between timing of surgical intervention and length of stay (P = 0.4).

Background The nasal valves constitute the majority of the nasal cavity's resistance. Any reduction in this already narrow area can cause a significant reduction in the nasal airflow. In this present study, the aim was to do an endoscopic assessment of the internal nasal valve (INV) in patients with various nasal septal deviations, with or without external nasal deformity. We measured endoscopically the INV in various nasal deformities and derived its association with the INV on anterior rhinoscopy and endoscopic assessment. Method We included 75 patients in the study who were analyzed for angle and grade of the INV by anterior rhinoscopic examination and Hopkins rod zero-degree nasal endoscope (Karl Storz SE & Co., Tuttlingen, Germany). Nasal septal deviations were also studied with respect to the Mladina classification. Correlation between various nasal septal deviations with the INV was done. Since studies addressing the classification of INV are not available in the literature, for the purpose of simplification of observation of INV angle, (normal range 9-15 degrees), subjective stratification was made in the study, i.e. below 9, 9-15, and more than 15 degrees for the sake of knowing the underlying cause and its relationship. Result An anterior rhinoscopic examination was performed on 75 patients. INV Grade 1 was the most common, with 18 patients of (69.2%), 15 patients of DNS with caudal dislocation (55.6%), five patients of DNS with spur (38.5%), and four patients of DNS with external nasal deformity (50%). The next frequently observed Grade of INV on anterior rhinoscopy examination was Grade 2, in 11 patients of DNS with caudal dislocation (40.7%), four patients of DNS with spur (30.8%), and three patients of DNS with external deformity (37.5%), which was statistically significant in our study. In the majority of patients with all types of nasal septal deviations with or without external nasal deformity, INV (angle) of less than 9 degrees was noted, which was statistically significant. A linear relationship, ie., Grade 0 INV in Type I, Grade 1 INV in types II, III, IV, and V, and Grade 2 in Type VII was observed. Our study is on par with the literature questioning the dogma of the normal angle of INV being 9-15 degrees. Conclusion We were able to establish a positive and complimentary role of anterior rhinoscopic and endoscopic assessment of INV. The proposed novel classification of the angle of INV by endoscopic assessment gives a better insight into the association of INV with various nasal septal deformities with or without external nasal septal deviation.

Trauma is an ever increasing problem and it is the leading cause of morbidity and mortality in the under 40s age group. The main purpose of this study is to determine the pattern of death related to trauma cases presenting to the emergency department (ED) of a university hospital. This was a retrospective analysis of 75 consecutive trauma case records at a university hospital for a one year period. The most common cause of deaths is motor vehicle crashes. The mean score for the injury severity score (ISS) and revised trauma score (RTS) on arrival to the ED among the succumbed patients were 27.8 (s.d 8.6) and 5.7 (s.d 1.1) respectively. 58.7% of deaths occurred within 48 hours after the admission. Less than 50% of studied patients were still alive beyond 45 hours post admission and less than 10% still alive beyond 11 days. Our analysis also showed that 28% (n=21) and 56% (n=41) of the studied sample had a probability of survival between 50% to 75% and more than 75% respectively upon ...

There is a need to increase access to surgical treatments in African countries, but perioperative complications represent a major global health-care burden. There are few studies describing surgical outcomes in Africa. We did a 7-day, international, prospective, observational cohort study of patients aged 18 years and older undergoing any inpatient surgery in 25 countries in Africa (the African Surgical Outcomes Study). We aimed to recruit as many hospitals as possible using a convenience sampling survey, and required data from at least ten hospitals per country (or half the surgical centres if there were fewer than ten hospitals) and data for at least 90% of eligible patients from each site. Each country selected one recruitment week between February and May, 2016. The primary outcome was in-hospital postoperative complications, assessed according to predefined criteria and graded as mild, moderate, or severe. Data were presented as median (IQR), mean (SD), or n (%), and compared u...

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

BackgroundPostoperative acute kidney injury (AKI) is a common complication of major gastrointestinal surgery with an impact on short- and long-term survival. No validated system for risk stratification exists for this patient group. This study aimed to validate externally a prognostic model for AKI after major gastrointestinal surgery in two multicentre cohort studies.MethodsThe Outcomes After Kidney injury in Surgery (OAKS) prognostic model was developed to predict risk of AKI in the 7 days after surgery using six routine datapoints (age, sex, ASA grade, preoperative estimated glomerular filtration rate, planned open surgery and preoperative use of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker). Validation was performed within two independent cohorts: a prospective multicentre, international study (‘IMAGINE’) of patients undergoing elective colorectal surgery (2018); and a retrospective regional cohort study (‘Tayside’) in major abdominal surg...

Ever since the Institute of Medicine (IOM) published its landmark report in 2001, Crossing the Quality Chasm: A New Health System for the 21 st Century, the concept of patient-centered healthcare has become popular and engaging around the world. Clinicians of diverse professional background have embraced the concept and institutions and governments are directing policies of healthcare delivery along the new concept. The vast majority view it as an innovative approach that emphasizes the participation of patients and families in decisions about their care in a mutually beneficial manner.

Modern medical practice has evolved into a highly structured and standardised practice, where guidelines have been refined to ensure consistent and safe care for patients, regardless of geographical location or healthcare provider. These guidelines have been established through years of continuous learning and tailoring to promote the safest possible medical practices. However, in order to further enhance patient care and prepare the next generation of physicians with even better guidelines, a proactive approach to reviewing and improving current teachings is needed. In this regard, structured reflection is often spoken about as a valuable tool in various medical settings, including surgery. There is currently too little emphasis on reflective practice in a formal and structured setting in the field of surgery. In this high-stakes field, a split-second decision can have life-or-death consequences, and thus it is crucial for surgeons to continuously reflect on their experiences, assess their performance, and identify areas for improvement. A framework for reflection was suggested in this study, combining individual and collective reflection. Each member of the surgical team was encouraged to reflect on their own experiences and observations individually and then share these reflections with the team in a protected environment. The team then worked collaboratively to agree on a collective response and plan of action, which helped identify areas for improvement and led to a shared understanding of best practice for patient care. This framework encourages continuous learning and improvement in the surgical team, reducing cognitive biases that may occur in large team-based discussions. Appraising conventional surgical practices, decision-making processes, and outcomes is crucial to enhancing patient care and gaining a deeper insight into the human factors involved in clinical outcomes.

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Background: A systematic literature review and metaanalysis was conducted to assess the association between intraoperative surgical skill and clinical outcomes. Methods: Peer-reviewed, original research articles published through August 31, 2021 were identified from PubMed and Embase. From the 1,513 potential articles, seven met eligibility requirements, reporting on 151 surgeons and 17,932 procedures. All included retrospective assessment of operative videos. Associations between surgical skill and outcomes were assessed by pooling odds ratios (OR) using random-effects models with the inverse variance method. Eligible studies included pancreaticoduodenectomy, gastric bypass, laparoscopic gastrectomy, prostatectomy, colorectal, and hemicolectomy procedures. Results: Meta-analytic pooling identified significant associations between the highest vs. lowest quartile of surgical skill and reoperation (OR: 0.

In recent years, the management of synchronous colorectal liver metastasis has changed significantly. Alternative surgical strategies to the classical colorectal-first approach have been proposed. These include the liver-first and combined resections approaches. The objectives of this review were to compare the short- and long-term outcomes for all three approaches. A systematic review of comparative studies was performed. Evaluated endpoints included surgical outcomes (5-year overall survival, 30-day mortality, and post-operative complications). Pair-wise and network meta-analysis (NMA) were performed to compare survival outcomes. Eighteen studies were included in this review, reporting on 3,605 patients. NMA and pair-wise meta-analysis of the 5-year overall survival did not show significant difference between the three surgical approaches: combined versus colorectal-first, mean odds ratio (OR) 1.02 (95% CI 0.8-1.28, P = 0.93); liver-first versus colorectal-first, mean OR 0.81 (95%...

Background: Emergency general surgery (EGS) is a high-risk process and is associated with poor outcomes and high mortality. This study aimed to evaluate the service delivery factors in a tertiary referral centre which may influence patient outcomes in emergency general surgery. Methods: Data on consecutive patients undergoing emergency laparotomy in a tertiary referral centre were prospectively collected from July 2017eJuly 2018. An extensive review of patient charts and IT systems was performed to extract demographic, clinical and care pathway data. Transfers for surgery from within the institution or within the centralised hospital network were recorded. Results: The unadjusted 30-day mortality rate in 163 patients undergoing emergency laparotomy was 13%. On multivariate analysis, 30-day mortality was significantly associated with p-POSSUM predicted mortality (p ¼ 0.003), p-POSSUM predicted morbidity (p ¼ 0.01), SORT mortality (p ¼ 0.004), ICU admission (p ¼ 0.02), ASA grade (p < 0.001) and transfer from non-surgical services (p < 0.001). 19.2% of patients were transferred from a referring hospital for emergency laparotomy. There was no association between inter-hospital transfer and 30-day mortality while increased mortality was observed in patients admitted to non-surgical services who required laparotomy (p < 0.001). Conclusion: Inter-hospital transfer for emergency laparotomy was not associated with increased mortality. Increased mortality was observed in patients admitted to non-surgical services who subsequently required emergency laparotomy. Configuration of emergency general surgery services must accommodate safe and effective transfer of patients, both between and within hospitals.

Background Emergency laparotomy (EL) is accompanied by high post-operative morbidity and mortality which varies significantly between countries and populations. The aim of this study is to report outcomes of emergency laparotomy in Greece and to compare them with the results of the National Emergency Laparotomy Audit (NELA). Methods This is a multicentre prospective cohort study undertaken between 01.2019 and 05.2020 including consecutive patients subjected to EL in 11 Greek hospitals. EL was defined according to NELA criteria. Demographics, clinical variables, and post-operative outcomes were prospectively registered in an online database. Multivariable logistic regression analysis was used to identify independent predictors of post-operative mortality. Results There were 633 patients, 53.9% males, ASA class III/IV 43.6%, older than 65 years 58.6%. The most common operations were small bowel resection (20.5%), peptic ulcer repair (12.0%), adhesiolysis (11.8%) and Hartmann’s procedu...

Background: With the widespread application of robotic systems and the increasing number of studies comparing robotic right colectomy (RRC) and laparoscopic right colectomy (LRC), there is a need for an up-to-date systemic review and meta-analysis assessing the advantages of this technique. Methods: The systemic review was performed in Medline, Scopus, Embase, Cochrane Oral Health Group Specialized Register and Google Scholar databases searching for studies comparing RRC and LRC, with no date restriction but limited to English and French literature. Two independent reviewers performed data extraction and qualitative synthesis. Random-effects models were used to summarize the risk ratio (RR) and mean differences (MD) with 95% confidence interval (CI). Results: Twenty-six non-randomized clinical trials (NRCTs) and 1 RCT were included. Overall, 2,314 patients underwent RRC and 17,791 LRC. Operative time was significantly longer for RRC with a MD of 45.36 min (95% CI: 31.75-58.97; P<0.00001). Conversion rate was significantly lower in the RRC group with a RR of 0.47 (95% CI: 0.27-0.81; P=0.007, I 2 =33%). Also, the number of harvested lymph node was significantly higher in the RRC group than the LRC group, with a MD of 2.03 (95% CI: 0.45-3.61; P=0.01, I 2 =68%). Estimated blood loss favored RRC, with a MD of −8.68 (95% CI: −17.27 to −0.08; P=0.05, I 2 =46%). There was no difference in the overall complication rate, mortality, anastomotic leakage, and time to first flatus. However, a significantly shorter hospital stay was associated with RRC, with a MD of −0.60 (95% CI: −1.01 to −0.19; P=0.004, I 2 =64%). No quantitative analysis could be performed for oncological outcomes. RRC was associated with significantly higher costs (MD 3,185.50 USD; 95% CI: 720.98-5650.02; P=0.01, I 2 =94%). Conclusions: RRC is a safe procedure that may offer certain advantages over LRC as lower conversion rate, blood loss, hospital stay. However, this should be balanced out with increased operative time and higher costs.

There is urgent need to improve access to safe surgical treatments for patients in low-and middle-income countries (LMICs). However, few data exist to characterise clinical outcomes for this patient population. Methods: Consecutive patients undergoing surgery at a referral hospital in Uganda were prospectively followed between October 2016 and October 2017. The primary outcome was in-hospital, postoperative mortality. Secondary outcomes were in-hospital complications for patients undergoing laparotomy and Caesarean section. Results are presented as n (%) or odds ratios (OR) with 95% confidence intervals. Results: A total of 4 773 patients of mean age 28 years were included; 3 754 were female (79.0%) and 4 259 patients (89.4%) were classified as American Society of Anesthesiologists class I or II. Some 3 501 (73.8%) procedures were performed on an emergency basis. The most frequent procedure was Caesarean section (2 634 patients [55.3%]). There were 93 deaths (2.0%), 49 of which occurred after the day of surgery (59.0%). In multivariable analysis, patients undergoing general (abdominal) surgery were at greatest risk of death (OR 4.34 [2.02-9.30]). Postoperative complications were recorded for 24/412 (5.8%) patients undergoing Caesarean section and 18/107 (16.8%) patients undergoing emergency laparotomy. Infection was the most frequent complication in these patient groups (33/519 patients [6.4%]). Conclusions: This study confirms the feasibility of longitudinal audit of postoperative outcomes in LMICs. Data collected over a one-year period were highly consistent with the findings of a recent seven-day cohort study conducted across Africa.

Background: Children comprise a large proportion of the population in sub-Saharan Africa. The burden of paediatric surgical disease exceeds available resources in Africa, potentially increasing morbidity and mortality. There are few prospective paediatric perioperative outcomes studies, especially in low-and middle-income countries (LMICs). Methods: We conducted a 14-day multicentre, prospective, observational cohort study of paediatric patients (aged <16 yrs) undergoing surgery in 43 government-funded hospitals in South Africa. The primary outcome was the incidence of in-hospital postoperative complications. Results: We recruited 2024 patients at 43 hospitals. The overall incidence of postoperative complications was 9.7% [95% confidence interval (CI): 8.4e11.0]. The most common postoperative complications were infective (7.3%; 95% CI: 6.2e8.4%). In-hospital mortality rate was 1.1% (95% CI: 0.6e1.5), of which nine of the deaths (41%) were in ASA physical status 1 and 2 patients. The preoperative risk factors independently associated with postoperative complications were ASA physcial status, urgency of surgery, severity of surgery, and an infective indication for surgery. Conclusions: The risk factors, frequency, and type of complications after paediatric surgery differ between LMICs and high-income countries. The in-hospital mortality is 10 times greater than in high-income countries. These findings

Accurate and reproducible automated segmentation of human hippocampal subfields is of interest to study their roles in cognitive functions and disease processes. Multispectral structural MRI methods have been proposed to improve automated hippocampal subfield segmentation accuracy, but the reproducibility in a multicentric setting is, to date, not well characterized. Here, we assessed test–retest reproducibility of FreeSurfer 6.0 hippocampal subfield segmentations using multispectral MRI analysis pipelines (22 healthy subjects scanned twice, a week apart, at four 3T MRI sites). The harmonized MRI protocol included two 3D-T1, a 3D-FLAIR, and a high-resolution 2D-T2. After within-session T1 averaging, subfield volumes were segmented using three pipelines with different multispectral data: two longitudinal (“long_T1s” and “long_T1s_FLAIR”) and one cross-sectional (“long_T1s_FLAIR_crossT2”). Volume reproducibility was quantified in magnitude (reproducibility error—RE) and space (DICE co...

Surgical grand rounds at a university hospital and the application of "publication presentation index" to evaluate outcomes-Should we now finally move towards publish and flourish? Author contribution AJFwriting, editing, final approval. RAconcept, editing, final approval.

Background: Reported data suggest that 4.2 million deaths will occur within 30 days of surgery worldwide each year, half of which are in low-and middle-income countries. Postoperative complications are a leading cause of long-term morbidity and mortality. Patients who survive and leave the hospital after surgical complications regularly experience reductions in long-term survival and functional independence, resulting in increased costs. With a high volume of surgery performed, there is a growing perception of the substantial impact of even minor enhancements in perioperative care. The Latin American Surgical Outcomes Study (LASOS) is an international, multicentre, prospective cohort study of adults submitted to in-patient surgery in Latin America aiming to provide detailed data describing postoperative complications and surgical mortality. Methods: LASOS is a 7 day cohort study of adults undergoing surgery in Latin America. Details of preoperative risk factors, intraoperative care, and postoperative outcomes will be collected. The primary outcome will be in-hospital postoperative complications of any cause. Secondary outcomes include in-hospital all-cause mortality, duration of hospital stay after surgery, and admission to a critical care unit within 30 days after surgery during the index hospitalisation. Results: The LASOS results will be published in peer-reviewed journals, reported and presented at international meetings, and widely disseminated to patients and public in participating countries via mainstream and social media. Conclusions: The LASOS may augment our understanding of postoperative complications and surgial mortality in Latin America. Clinical trial registration: NCT05169164.

Background Transanal total mesorectal excision (taTME) is a safe and effective technique. We have progressively developed a systematic approach in the single-surgeon setting. The aim of this study was to compare our early vs late single-surgeon taTME experience as well as present the technical and logistical modifications that were crucial to achieve successful implementation of a taTME program. Methods Review of prospectively collected data on 27 patients who had taTME in June 2015-September 2016 (early cohort) was included and compared with 43 patients who underwent taTME in October 2016-September 2017 (late cohort). Procedures were performed by a single-surgeon team at Health Sciences North (Sudbury, Ontario, Canada). Inclusion criteria were T1-3 or downstaged T4 mid-and low-rectal lesions. Cases of non-neoplastic disease were excluded. Outcomes assessed included mesorectal integrity, margin status, operative time, complications, morbidity, length of stay and 30-day readmission. Results A total of 70 cases were included. Patients were divided into early (27 patients, 14 males; mean age 60.74 ± 9.77 years) and late (43 patients, 29 males; mean age 63.48 ± 10.85 years) cohorts. During the early phase, procedural modifications including regular takedown of the splenic flexure, intra-corporeal division of the mesentery, liberal use of a Pfannenstiel incision for extraction, abundant washing of the surgical field and regular use of the ICG technology were progressively introduced. There was no mortality nor statistically significant difference between the early and late cohort in terms of morbidity (33.3 vs 39.4% p = 0.727), anastomotic leak (14.8 vs 4.6% p = 0.19), operating time (5.05 ± 1.26 vs 4.96 ± 1.14 h p = 0.755), length of stay (4.0 ± 2.54 vs 4.81 ± 3.63 days p = 0.394) and CRM negative margin (96.3 vs. 97.7% p = 0.999), and no incomplete specimens were obtained on either cohort. Conclusions This study confirms the safety and effectiveness of single-surgeon implementation of taTME technique. Technical challenges experienced in this setting were not obstacles for further refinement and to establish a tendency towards better outcomes. Overcoming technical challenges is possible, familiarity with taTME is slow yet progressive, and improvement tends to occur with experience.

Background The most important advancement in the surgical management of rectal cancer has been the introduction of total mesorectal excision (TME). Technical limitations to approaching mid and distal lesions remain. The recently described transanal TME makes it possible to minimize some of the difficulties by improving access. Anastomotic leak is a persistent concern after colorectal surgery no matter what technique is used. The objective of this study was to explore the impact of experience on the incidence of anastomotic leak after transanal TME. Secondary endpoints were local recurrence and margin status. Methods A retrospective cohort study was conducted over a period of 3 years at a tertiary care center in Northern Ontario with high volume of rectal cancer patients. The initial 100 consecutive patients with rectal neoplasia who had transanal TME surgery were included. All cases were performed by a single team. The main outcome assessed was the incidence of anastomotic leak beyo...

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