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Objectives: The study (PreopWeek) aimed to assess the perioperative nutritional care for major surgical patients in Brazilian hospitals, focusing on adherence to emerging multimodal protocols like Enhanced Recovery After Surgery and Acceleration of Total Postoperative Recovery., Methods: An observational cross-sectional study was conducted in Brazilian hospitals enrolled voluntarily from June 19 to June 23, 2023 (convenience sample). Data were collected through patient interviews and medical records review., Results: Data from 219 patients up to the fifth postoperative day or postoperative discharge across 24 hospitals were analyzed. Only three hospitals (12.5%) had established institutional perioperative protocols. Most of the patients were female (60.3%) and over 60 y old (81.7%) and underwent gastrointestinal (34.7%) or orthopedic (33.3%) surgeries. General and nutritional preoperative counseling was provided to a respective 82.2% and 62.6% of the patients. Only 25.7% of the patients had preoperative fasting for up to 3 h, and 28.8% received carbohydrate-rich supplements. Immunonutrition was not received by 43.8% at any point. Although most started postoperative refeeding within 24 h (81.7%), 39.4% started with a liquid diet and 70.6% reported postoperative immobilization in the first 24 h. Notable differences were observed between hospitals with and without protocols. Hospitals with institutional protocols reported significantly more preoperative exercises and nutritional counseling and higher adherence rates for all the perioperative protocols., Conclusions: Our study demonstrates a lack of adherence to the multimodal protocols, even in hospitals with institutional protocols. Future educational programs are necessary to improve this result., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. Maria Cristina Gonzalez reports that financial support was provided by the Brazilian Society of Parenteral and Enteral Nutrition (with a grant from Nestle Health Science Brazil). Thiago J. M. Goncalves reports that financial support was provided by the Brazilian Society of Parenteral and Enteral Nutrition (with a grant from Nestle Health Science Brazil). Silvana P. Orlandi reports that financial support was provided by the Brazilian Society of Parenteral and Enteral Nutrition (with a grant from Nestle Health Science Brazil). Pedro E. Portari-Filho reports that financial support was provided by the Brazilian Society of Parenteral and Enteral Nutrition (with a grant from Nestle Health Science Brazil). Antonio Carlos L. Campos reports that financial support was provided by the Brazilian Society of Parenteral and Enteral Nutrition (with a grant from Nestle Health Science Brazil). Maria Cristina Gonzalez reports relationships with Danone Medical Nutrition Holding BV and Abbott Laboratories that include speaking and lecture fees and a relationship with Nestle Health Science Brazil that includes travel reimbursement. Thiago J. M. Goncalvez reports a relationship with Nestle Health Science Brazil that includes speaking and lecture fees. Valéria A. Rosenfeld reports a relationship with Nestle Health Science Brazil that includes employment. Pedro E. Portari-Filho reports relationships with Nestle Health Science Brazil, Baxter Brazil, and Fresenius Kabi Brazil that include speaking and lecture fees. Antonio Carlos L. Campos reports a relationship with Nestle Health Science Brazil that includes speaking and lecture fees., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Transfusion of blood products following cardiothoracic surgery represents a significant proportion of national blood product usage, has significant cost implications and is associated with increased 30-day mortality. Following identification of an increase in blood product use, we implemented a healthcare improvement initiative using a perioperative care model and establishment of a new multispecialty cardiothoracic surgery taskforce to further define and tackle the problem. The initiative incorporated a bundle of preoperative identification of high-risk patients, an intraoperative haemostasis checklist, a programme of unit education focussing on bleeding postbypass and use of thromboelastography and introduction of postoperative protocols for identification and escalation of bleeding. Following intervention, a 60% reduction in blood product use within the first 12 hours of cardiopulmonary bypass was observed. Red cell, cryoprecipitate and fresh frozen plasma usage were particularly reduced with 57%, 47% and 72% reductions, respectively, following intervention and similar results were maintained on repeat audit 1-year postintervention, with on average 84 fewer blood products used per 100 patients. This resulted in an estimated cost saving of AU$36 928 per 100 patients. This quality initiative was successful in overcoming traditional silos of care and describes how quality improvement methodology utilising a multispecialty and multidisciplinary approach can be applied to solve complex issues in the perioperative period. Here, we demonstrate a reproducible and sustainable model for reducing blood product use in the cardiothoracic perioperative population., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Study Objectives: This study aimed to assess the effect of perioperative rehabilitation exercise, initiated shortly after hospital admission, on postoperative outcomes in elderly patients., Design: A prospective, multicenter, randomized, controlled, open-label, and assessor-blinded clinical trial., Setting: Hospital wards., Patients: Elderly patients (≥65 years, n = 160) scheduled for gastrointestinal surgery between June 2021 and November 2022 were enrolled and randomly assigned to the intervention or control group., Interventions: Patients were divided into two groups base on whether they had received a specific type of exercise program initiated after hospital admission and continued until 30 days after surgery., Measurements: The primary outcome was the Comprehensive Complications Index (CCI) measured at 30 days after surgery. Secondary outcomes were the rate of complications, number of complications, patient satisfaction, hospital readmission, postoperative length of stay, gastrointestinal function recovery, postoperative quality of life and psychological status. Intention-to-treat (ITT) and per-protocol (PP) analyses were conducted., Main Results: ITT analysis showed a significantly lower 30-day CCI in the intervention group (β: -6.31; 95 % Confidence Interval [CI], -11.26 to -1.37, P = 0.013). Compared to controls, the intervention group had a decreased rate of hospital readmission (Odds Ratio: 0.00; 95 % CI, 0.00 to 0.32, P = 0.022), less number of complications (β: -0.57; 95 % CI, -1.03 to -0.11, P = 0.016), as well as lower rate of postoperative anxiety (β: -0.74; 95 % CI, -1.42 to -0.06, P = 0.033) and depression scores (β: -1.13; 95 % CI, -0.97 to -1.30, P = 0.008). Additionally, the intervention group reported higher satisfaction (β: 0.98; 95 % CI, 0.33 to 1.64, P = 0.004) and Euro quality of life-Visual Analogue Scale scores (β: 8.88; 95 % CI, 2.48 to 15.28, P = 0.007). Similar results were found in the PP analysis., Conclusion: Perioperative rehabilitation exercise has a positive impact on postoperative complications, quality of life and psychological well-being in elderly patients undergoing gastrointestinal surgery, even when implemented after hospital admission., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Study Objective: Newer regional anesthesia techniques and minimally invasive surgeries have yielded decreased postoperative pain scores, potentially leading to decreased need for perioperative epidural analgesia. Limited literature is available on trends in usage rates of epidurals. The objective of this study was to identify trends in perioperative epidural analgesia rates among multiple fields of surgery., Methods: All patients undergoing general, thoracic, urologic, plastic, vascular, orthopedic, or gynecological surgery in 2014-2020 were included from the National Surgical Quality Improvement Program database of over 700 hospitals in the U.S. and 11 different countries. Annual trends in epidural analgesia for all surgeries and each surgical specialty were assessed by mixed effects multivariable logistic regression. The odds ratios (OR) and 99 % confidence intervals (CI) were reported., Results: There were 3,111,435 patients from 2014 to 2020 that were included in the final analysis, in which 107,209 (3.4 %) received perioperative epidural analgesia. Among all surgeries combined, epidural use throughout the study period decreased (OR 0.98 per year, 99 % CI 0.97-0.98, P < 0.001). When only analyzing the surgeries with the top 5 most frequent epidural use per specialty, there was no statistically significant trend in epidural utilization (OR 0.99 per year, 99 % CI 0.99-1.00, P = 0.09). However, there was an increasing trend in epidural utilization in general surgery (OR 1.05 per year, 99 % CI 1.03-1.07, P < 0.001) and vascular surgery (OR 1.08 per year, 99 % CI 1.05-1.10, P < 0.001)., Conclusion: Rates of perioperative epidural analgesia use has decreased in recent years overall, however, among surgeries within the general surgery and vascular surgery specialty, utilization has increased for procedures that have the highest rates of usage., Competing Interests: Declaration of competing interest RG's institution has received funding and/or product for research purposes from Epimed, Infutronix, SPR Therapeutics, Merck, and Precision Genetics. RG is a consultant for Avanos., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Study Objective: A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs., Design: Multicenter retrospective cohort study., Setting: Two academic healthcare networks in New York and Massachusetts, USA., Patients: 46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021., Interventions: The primary exposure was the median intraoperative dynamic driving pressure., Measurements: The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications., Main Results: The median intraoperative dynamic driving pressure was 17.2cmH 2 O (IQR 14.0-21.3cmH 2 O). In adjusted analyses, every 5cmH 2 O reduction in dynamic driving pressure was associated with a decrease of -0.7% in direct perioperative healthcare-associated costs (95%CI -1.3 to -0.1%; p = 0.020). When a dynamic driving pressure below 15cmH 2 O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI -US$546 to -US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; -US$1755;97.5%CI -US$2495 to -US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively)., Conclusions: Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients., Competing Interests: Declaration of competing interest Daniel Talmor received speaking fees and grant funds from Hamilton Medical, Inc. and Mindray Medical, outside the submitted work. Matthias Eikermann received grants from Merck & Co and serves as an Associate Editor for the British Journal of Anaesthesia. Maximilian S. Schaefer received funding for investigator-initiated studies from Merck & Co., which do not pertain to this manuscript. He is an associate editor for BMC Anesthesiology. He received honoraria for lectures from Fisher & Paykel Healthcare and Mindray Medical International Limited. He received an unrestricted philanthropic grant from Dr. Jeffrey and Judith Buzen. All other authors have no support from any organization for the submitted work, no financial relationships with any organizations that might have an interest in the submitted work in the previous three years, and no other relationships or activities that could appear to have influenced the submitted work. This work was supported by an unrestricted grant from Dr. Jeffrey and Judith Buzen to Maximilian S. Schaefer. Dr. Jeffrey and Judith Buzen had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Nutrition is critical to gastrointestinal (GI) disease prevention and treatment, including operations, yet perioperative nutrition practices vary widely. We aimed to understand GI surgical patient and health care provider's perioperative nutrition beliefs and practices., Materials and Methods: We used a mixed-methods approach, including a patient survey (n = 19), provider survey (n = 26), and semistructured interviews with a subset of providers (n = 15). Providers included surgeons, gastroenterologists, medical oncologists, advanced practice providers, and dietitians. Provider interviews were transcribed, iteratively coded, and thematically analyzed. Quantitative and qualitative data were integrated., Results: 94.7% of patients and 100% of providers surveyed believe that nutrition affects outcomes. Patients seek nutrition information from diverse resources (73.7% from websites or blogs, 42.1% from documentaries, and 36.8% from books or /magazines) and people (52.6% from family members, 42.1% from a significant other, partner, or spouse, and 36.8% from a dietitian or nutritionist). Providers cited a lack of quality information, misinformation, and inconsistency among health care providers as barriers to high-quality nutrition care. Both patients and providers noted that nutritional supplements have drawbacks, with 100% of patients and 96.2% of providers expressing interest in house- made plant-based protein smoothie or soup alternatives., Conclusions: This study led to the development of a multidisciplinary task force, which has collaborated on multiple interventions to improve inpatient perioperative surgical nutrition (e.g., smoothie pilot and postoperative menu revisions)., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Electronic consultations (e-consults) for periprocedural hematologic questions were introduced at the VA Connecticut Healthcare System in 2011. We sought to explore the relationship between the availability of e-consults, referral patterns, and surgical outcomes., Methods: A single-center retrospective study of all perioperative hematologic consultations from 2006 to 2018 was conducted. Patient characteristics, indications, and outcomes were analyzed. Primary outcome measures were time from consult to surgery and operative morbidity via Clavien-Dindo classification. Secondary outcomes included consult volume and procedural outcomes of interest., Results: Of 357 consultations, 62% were conducted via e-consults. 68.3% had associated procedural data and constituted the study cohort. Annual consult volume increased from 7 in 2006 to 41 in 2018, a 5.8-fold increase. E-consults comprised 20% of consults in 2011 but had risen to 92.3% in 2018. Time to resolution of e-consults after 2011 improved compared to pre-face-to-face (FTF-pre, P = 0.001) and FTF-post (P = 0.002). Time from consult to surgery remained unchanged. 8.4% had major complications (Clavien-Dindo >2) with readmission or reoperation occurring in 4.0% and 3.7%, respectively. Intraoperative and postoperative transfusions were required in 15.2% and 13.1% of cases, respectively. Hematologic complications (i.e., deep vein thrombosis/pulmonary embolism) occurred in 3.5%. Comparison between FTF and e-consults revealed no significant differences in these outcomes (P > 0.05, all)., Conclusions: E-consults for perioperative hematologic issues were rapidly adopted and addressed more quickly than FTF consultation while time to surgery was unchanged despite increased consult volume. Adoption of the e-consult model was not associated with changes in the assessed operative outcomes., (Published by Elsevier Inc.)

Background: Immediate breast reconstruction (IBR) is a common oncoplastic procedure used in breast cancer surgery. This study aims to investigate compliance with prosthetic breast reconstruction guidelines and its impact on perioperative treatment., Methods: We reviewed data from the National Clinical Database-Breast Cancer Registry between January 2019 and December 2020. We compared perioperative treatment implementation between the IBR and non-IBR groups by subtype matching for age, menopausal status, T stage, N stage, and histology., Results: A total of 8,860 patients with breast cancer who underwent IBR (6,075 breast prostheses, 2,492 autologous tissues, and 293 others) were identified. The compliance rate with the guidelines for prosthetic breast reconstruction was 97.7%. After matching, chemotherapy for luminal A-like diseases was significantly less frequent in the IBR group than in the non-IBR group (16.3% vs 20.5%, p < 0.001), and radiotherapy was less frequent in luminal A-like and HER2-positive patients (7.2% vs 9.0%, p = 0.010 and 7.1% vs 11.4%, p = 0.005, respectively). Among the 1-3 node-positive cases, fewer patients with prosthetic IBR received radiotherapy than those without IBR (15.7% vs 26.4%, p < 0.001)., Conclusion: Prosthetic breast reconstruction was performed with strict adherence to the Japanese guidelines. The implementation rates of chemotherapy and radiotherapy were lower in the specific IBR group than those in the non-IBR group. Therefore, large-scale, long-term follow-up data are required., (© 2024. The Author(s).)

Surgical patients are often transfused to manage bleeding and anemia. Best practices for red blood cell (RBC) transfusion administration in patient having noncardiac surgery remains controversial and a robust evaluation and description of perioperative transfusion practices is lacking. We characterized perioperative hemoglobin concentrations and transfusion practices from the prospective VISION cohort which included 39,222 patients aged ≥45 years who had inpatient noncardiac surgery. Variations in transfusion practices were analyzed using hierarchical mixed models, and associations with mortality and complications were evaluated using a nested frailty survival model. Within the cohort, 16.1% (n = 6296) were given perioperative RBC transfusions, with the fraction declining from 20% to 13% over the 6-year study period. The proportion of patients transfused varied by surgery type from 6.4% for low-risk operations (i.e., minor surgery) to 31.5% for orthopedic surgeries. Variations were largely associated with patient hemoglobin concentrations, but also with center (range: 3.7%-27.3%) and country (0.4%-25.3%). Even after adjusting for baseline hemoglobin, comorbidities and type of surgery, both center and country were significant sources of variation in transfusion practices. Among transfused participants, 60.4% (n = 3728/6170) had at least 1 hemoglobin concentration ≤80g/L and 86.0% (n = 5305/6170) had at least 1 hemoglobin concentration ≤90g/L, suggesting that relatively restrictive transfusion strategies were used in most. The proportion of patients receiving at least 1 RBC transfusion declined from 20% to 13% over 6 years. However, there was considerable unexplained variation in transfusion practices., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Peri-operative blood transfusion has been identified as a risk factor for anastomotic leak in recent studies, but little is known about which patients are at risk for blood transfusion. This study aims to assess the relationship between blood transfusion and anastomotic leak and factors predisposing to leak in patients undergoing colorectal cancer surgery., Methods: This retrospective cohort study was conducted in a tertiary hospital in Brisbane, Australia, between 2010 and 2019. A total of 522 patients underwent resection of colorectal cancer with primary anastomosis with no covering stoma and the prevalence of anastomotic leak was compared between those who had had perioperative blood transfusion(s) and those who had not., Results: A total of 19 of 522 patients undergoing surgery for colorectal cancer had developed an anastomotic leak (3.64%). 11.3% of patients who had had a perioperative blood transfusion developed an anastomotic leak whereas 2.2% of patients who had not had a blood transfusion developed an anastomotic leak (p = 0.0002). Patients undergoing procedure on their right colon had proportionally more blood transfusions and this approached statistical significance (p = 0.06). Patients who received a greater quantity of units of blood transfusion prior to their diagnosis of anastomotic leak were more likely to develop an anastomotic leak (p = 0.001)., Conclusion: Perioperative blood transfusions are associated with a significantly increased risk of an anastomotic leak following bowel resection with primary anastomosis for colorectal cancer., (© 2023. The Author(s).)

Background: Various studies have demonstrated racial disparities in perioperative care and outcomes. The authors hypothesize that among lower extremity total joint arthroplasty patients, evidence-based perioperative practice utilization increased over time among all racial groups, and that standardized evidence-based perioperative practice care protocols resulted in reduction of racial disparities and improved outcomes., Methods: The study analyzed 3,356,805 lower extremity total joint arthroplasty patients from the Premier Healthcare database (Premier Healthcare Solutions, Inc., USA). The exposure of interest was race (White, Black, Asian, other). Outcomes were evidence-based perioperative practice adherence (eight individual care components; more than 80% of these implemented was defined as "high evidence-based perioperative practice"), any major complication (including acute renal failure, delirium, myocardial infarction, pulmonary embolism, respiratory failure, stroke, or in-hospital mortality), in-hospital mortality, and prolonged length of stay., Results: Evidence-based perioperative practice adherence rate has increased over time and was associated with reduced complications across all racial groups. However, utilization among Black patients was below that for White patients between 2006 and 2021 (odds ratio, 0.94 [95% CI, 0.93 to 0.95]; 45.50% vs. 47.90% on average). Independent of whether evidence-based perioperative practice components were applied, Black patients exhibited higher odds of major complications (1.61 [95% CI, 1.55 to 1.67] with high evidence-based perioperative practice; 1.43 [95% CI, 1.39 to 1.48] without high evidence-based perioperative practice), mortality (1.70 [95% CI, 1.29 to 2.25] with high evidence-based perioperative practice; 1.29 [95% CI, 1.10 to 1.51] without high evidence-based perioperative practice), and prolonged length of stay (1.45 [95% CI, 1.42 to 1.48] with high evidence-based perioperative practice; 1.38 [95% CI, 1.37 to 1.40] without high evidence-based perioperative practice) compared to White patients., Conclusions: Evidence-based perioperative practice utilization in lower extremity joint arthroplasty has been increasing during the last decade. However, racial disparities still exist with Black patients consistently having lower odds of evidence-based perioperative practice adherence. Black patients (compared to the White patients) exhibited higher odds of composite major complications, mortality, and prolonged length of stay, independent of evidence-based perioperative practice use, suggesting that evidence-based perioperative practice did not impact racial disparities regarding particularly the Black patients in this surgical cohort., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

Objective: To assess the incidence of post-operative non-ischaemic cerebral complications as a pivotal outcome parameter with respect to size of cerebral infarction, timing of surgery, and peri-operative management in patients with symptomatic carotid stenosis who underwent carotid endarterectomy (CEA)., Methods: Retrospective analysis of prospectively collected single centre CEA registry data. Consecutive patients with symptomatic carotid stenosis were subjected to standard patch endarterectomy. Brain infarct size was measured from the axial slice of pre-operative computed tomography/magnetic resonance imaging demonstrating the largest infarct dimension and was categorised as large (> 4 cm 2 ), small (≤ 4 cm 2 ), or absent. CEA was performed early (within 14 days) or delayed (15 - 180 days) after the ischaemic event. Peri-operative antiplatelet regimen (none, single, dual) and mean arterial blood pressure during surgery and at post-operative stroke unit monitoring were registered. Non-ischaemic post-operative cerebral complications were recorded comprising haemorrhagic stroke and encephalopathy, i.e., prolonged unconsciousness, delirium, epileptic seizure, or headache., Results: 646 symptomatic patients were enrolled of whom 340 (52.6%) underwent early CEA; 367 patients (56.8%) demonstrated brain infarction corresponding to stenosis induced symptoms which was small in 266 (41.2%) and large in 101 (15.6%). Post-operative non-ischaemic cerebral complications occurred in 12 patients (1.9%; 10 encephalopathies, two haemorrhagic strokes) and were independently associated with large infarcts (adjusted odds ratio [OR] 6.839; 95% confidence interval [CI] 1.699 - 27.534) and median intra-operative mean arterial blood pressure in the upper quartile, i.e., above 120 mmHg (adjusted OR 13.318; 95% CI 2.749 - 64.519). Timing of CEA after the ischaemic event, pre-operative antiplatelet regimen, and post-operative blood pressure were not associated with non-ischaemic cerebral complications., Conclusion: Infarct size and unintended high peri-operative blood pressure may increase the risk of non-ischaemic complications at CEA independently of whether performed early or delayed., Competing Interests: Conflict of interest and funding None., (Copyright © 2021 The Author(s). Published by Elsevier B.V. All rights reserved.)

Objectives: This study aimed to evaluate the application of cost-effectiveness modeling to redesign of perioperative care pathways, from a hospital perspective., Methods: A Markov cost-effectiveness model of patient transition between care locations, each with different characteristics and cost, was developed. Inputs were derived from clinical trials piloting a preoperative call center and a postoperative medium-acuity care unit. The effect chosen was days at home (DAH) after surgery, reflecting quality of in-hospital care, acknowledged financially by fundholders, and relevant to consumers. Cost was from the hospital's perspective. A model cycle time of 4 hours for 30 days reflected relevant timelines and costs., Results: A Markov model was successfully created, accounting for the care locations in the 2 pathways as model states and accounting for consequences and costs. Cost-effectiveness analysis allowed the calculation of an incremental cost-effectiveness ratio comparing these pathways, providing a mean incremental cost-effectiveness ratio of -$427 per additional DAH, where incremental costs and DAH were -$644 and +1.51, respectively. Probabilistic sensitivity analysis suggested the new pathway had a 61% probability of reduced costs and a 74% probability of increased DAH and a 58% probability this pathway was dominant. Tornado analysis revealed the major contributor to increased costs as intensive care unit stay and the major contributor to decreased costs as ward stay. For the new pathway, the probability of transfer from ward to home and the probability of staying at home had the greatest impact on DAH., Conclusions: These data suggest Markov modeling may be a useful tool for the cost-effectiveness analysis of initiatives in perioperative care., (Copyright © 2021 ISPOR–The International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. All rights reserved.)

BACKGROUND This single-center study compared the effect of combined thoracic paravertebral block (TPVB) and general anesthesia vs general anesthesia alone on postoperative stress and pain in patients undergoing laparoscopic radical nephrectomy. MATERIAL AND METHODS Patients undergoing laparoscopic radical nephrectomy were selected and randomized into a study group given TPVB combined with general anesthesia (n=43) and a reference group (n=43) given general anesthesia. The perioperative clinical indicators, blood pressure, pulse rate, visual analog scale (VAS) score, and adverse reactions were compared. RESULTS Perioperative clinical indicators of the study group (other than operation duration) were superior to those of the reference group (P<0.05). At 90 min in the operation, systolic blood pressure (SBP), diastolic blood pressure (DBP), and pulse rate were lower than before anesthesia (t=7.691, 10.017, and 7.728, P<0.05). SBP, DBP, and pulse rate at 90 minutes during operation were significantly lower in the study group than in the reference group (t=7.582, 8.754, and 6.682, P<0.01). The study group had lower VAS scores both during activity and at rest 48 h after the operation than in the reference group (t=5.171 and 6.025, P<0.001). The total incidence of adverse reactions in the study group was lower than in the reference group (χ²=5.018, P=0.024). CONCLUSIONS The findings from this study from a single center showed that TPVB combined with general anesthesia for patients undergoing laparoscopic radical nephrectomy significantly reduced postoperative pain and stress.

Background: Antiplatelet agents are typically withheld perioperatively because of bleeding concerns. Dual antiplatelet therapy, such as aspirin and clopidogrel, has significant morbidity and mortality benefits in patients with ischemic heart disease or peripheral vascular disease. This study aims to evaluate the impact of perioperative dual antiplatelet therapy in the lower extremity free tissue transfer population., Methods: Lower extremity free tissue transfers performed by the senior author (K.K.E.) from 2011 to 2019 were retrospectively reviewed. Demographics, comorbidities, perioperative dual antiplatelet therapy, and free tissue transfer characteristics were recorded. Outcomes of interest included flap success, hematoma formation, blood transfusion requirements, and cardiac event occurrence., Results: One hundred ninety-five free tissue transfers were included. Median age at the time of free tissue transfer was 56.5 years. Median Charlson Comorbidity Index was 3. Thirty-four patients were on clopidogrel, which was either withheld (n = 20) or continued (n = 14) on the day of free tissue transfer. Incidence of blood transfusion was significantly higher in both the withheld and continued versus nonclopidogrel groups. Flap success was statistically equivalent between groups (withheld, 90.0 percent; continued, 92.9 percent; nonclopidogrel, 95.0 percent; p = 0.346). Cardiac events occurred most often in the continued group (21.4 percent) compared to the withheld (5.0 percent) and nonclopidogrel (0.6 percent) groups. On multivariate analysis, holding clopidogrel remained significant for increased odds of postoperative transfusion. The clopidogrel group was no longer significant for intraoperative transfusion., Conclusions: Despite increases in volume of blood products transfused, free tissue transfer can be performed safely with perioperative dual antiplatelet therapy. Withholding dual antiplatelet therapy on the day of free tissue transfer was not associated with decreased intraoperative transfusion; thus, dual antiplatelet therapy can safely be continued throughout the operative course to minimize cardiovascular risk., Clinical Question/level of Evidence: Therapeutic, III., Competing Interests: Disclosure: The authors have no financial disclosures, commercial associations, or any other conditions posing a conflict of interest to report., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: The number of patients receiving anaesthesia is increasing, but the impact of general anaesthesia on the patient's immune system remains unclear. The aim of the present study is to investigate dynamics of systemic immune cell responses to anaesthesia during perioperative period at a single-cell solution., Methods: The peripheral blood mononuclear cells (PBMCs) and clinical phenomes were harvested and recorded 1 day before anaesthesia and operation, just after anaesthesia (0 h), and 24 and 48 h after anaesthesia. Single-cell sequencing of PBMCs was performed with 10× genomics. Subsequently, data analysis was performed with R packages: Seurat, clusterProfiler and CellPhoneDB., Results: We found that the cluster of CD56 + NK cells changed at 0 h and the cluster of monocytes increased at 24 and 48 h after anaesthesia. The characteristic genes of CD56 + NK cells were mainly enriched in the Jak-STAT signalling pathway and in cell adhesion molecules (24 h) and carbon metabolism (48 h). The communication between CD14 + monocytes and other cells decreased substantially 0 and 48 h after operation. The number of plasma cells enriched in protein export in men was substantially higher than that in women, although the total number in patients decreased 24 h after operation. CD14 + monocytes dominated that cell-cell communications appeared in females, while CD8 + NKT cells dominated that cell-cell communications appeared in male. The number of plasma cells increased substantially in patients with major surgical trauma, with enrichments of pentose phosphate pathway. The communications between plasma cells with other cells varied between surgical severities and anaesthetic forms. The intravenous anaesthesia caused major alterations of cell types, including CD14 + monocytes, plasmas cells and MAIT cells, as compared with inhalation anaesthesia., Conclusion: We initially reported the roles of perioperative anaesthesia/surgery in temporal phenomes of circulating immune cells at a single-cell solution. Thus, the protection against immune cell changes would benefit the recovery from anaesthesia/surgery., (© 2022 The Authors. Clinical and Translational Medicine published by John Wiley & Sons Australia, Ltd on behalf of Shanghai Institute of Clinical Bioinformatics.)

Objective: Tobacco use is common among vascular surgery patients and negatively impacts outcomes and longevity. In the second quarter of 2018, a statewide vascular quality collaborative launched an initiative across its 35 participating hospitals to promote smoking cessation at the time of surgery. This intervention was based on the Vascular Physician Offer and Report (VAPOR) trial and consisted of 3 components: brief physician-delivered advice, referral to telephone-based counseling, and nicotine replacement therapy. The goal of this study is to evaluate the results of this intervention., Methods: We performed a retrospective analysis of patients undergoing vascular surgery between 2018 and 2020. Procedures included open abdominal aortic aneurysm repair, endovascular aneurysm repair, open vascular bypass, open thrombectomy, carotid endarterectomy, and carotid stenting. The primary explanatory variables were receipt of tobacco cessation interventions as documented in the medical record. The primary outcome was tobacco cessation, captured during 30-day and 1-year chart review and/or patient follow-up. A multivariable logistic regression model was calculated to estimate the association of covariates with smoking cessation while adjusting for patient and clinical characteristics., Results: A total of 13,890 patients underwent surgery during the study period. The mean age was 69.4 ± 10 years; 4687 patients (34%) were female, and 5158 patients (37%) were current smokers. At least one smoking cessation component was delivered to 2245 patients (44% of smokers). The quit rate was 35% among 4671 patients with 30-day follow-up and 43% among 2936 patients with 1-year follow up. On multivariable regression, at 30 days, receiving two intervention components was associated with 1.29 (95% confidence interval [CI], 1.07-1.55) higher odds of quitting. At both time points, smoking cessation was also associated with undergoing an emergent procedure (30-day odds ratio [OR], 1.52; 95% CI, 1.16-1.99; 1-year OR, 1.41; 95% CI, 1.01-1.97) and undergoing open abdominal aortic aneurysm repair (30-day OR, 1.71; 95% CI, 1.20-2.43; 1-year OR, 1.75; 95% CI, 1.11-2.78)., Conclusions: In a cohort of vascular surgical patients where tobacco use was common, nearly one-half of patients quit smoking 1 year after surgery. Receiving two smoking cessation intervention components was associated with quitting at 30 days. Overall, these results demonstrate encouraging quit rates and identify an opportunity for longer-term intervention to maintain even greater 1-year tobacco cessation., (Copyright © 2021 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Carcinoid crises, defined as the sudden onset of hemodynamic instability in patients with neuroendocrine tumors undergoing operation, are associated with significantly increased risk of postoperative complications. Octreotide has been used prophylactically to reduce crisis rates as well as therapeutically to treat crises that still occur. However, studies using octreotide still report crisis rates of 3.4% to 35%, leading to the questioning of its efficacy., Methods: Patients with neuroendocrine tumors undergoing operation between 2017 to 2020 with no perioperative octreotide were prospectively studied. Clinicopathologic data were compared by χ 2 test for discrete variables and by Mann-Whitney U test for continuous variables., Results: One hundred and seventy-one patients underwent 195 operations. Crisis was documented in 49 operations (25%), with a mean duration of 3 minutes. Crisis was more likely to occur in patients with small bowel primary tumors (P = .012), older age (P = .015), and carcinoid syndrome (P < .001). Those with crises were more likely to have major postoperative complications (P = .003)., Conclusion: Completely eliminating perioperative octreotide resulted in neither increased rate nor duration compared with previous studies using octreotide. We conclude perioperative octreotide use may be safely stopped, owing to inefficacy, though the need for an effective medication is clear given continued higher rates of complications., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to examine perioperative medication patterns surrounding major amputation surgeries., Design: A retrospective chart review of 216 cases of major amputations (transfemoral, hip disarticulation, hemipelvectomy, forequarter) at an academic hospital was conducted, examining medications, dosing changes, and drug-drug interaction warnings preoperatively and postoperatively., Results: Medications increased in 76.9% (166/216), remained the same in 10.6% (23/216), and decreased in 12.5% (27/216) of cases. Average number of medications was 7 preoperatively and 10 postoperatively. In 189 cases with preoperative medications present, postoperative dosing remained the same for 74.3%, increased for 9.2%, decreased for 7.6%, and was unknown for 8.9% of medications. Increases in each of type C ("monitor therapy"), D ("consider therapy modification), and X ("avoid combination") drug-drug interaction warnings were seen respectively in 59.7%, 62.0%, and 5.1% of cases., Conclusion: Polypharmacy is involved preoperatively and increased postoperatively in most cases of major limb amputation, with agent dosing remaining the same or increased in most cases. Drug-drug interaction warnings also increase. These occur at a time of abrupt changes to the body's size, compartments, and physiologic responses. More research and clinical attention are warranted given anticipated changes in pharmacokinetics and pharmacodynamics., Competing Interests: Financial disclosure statements have been obtained, and no conflicts of interest have been reported by the authors or by any individuals in control of the content of this article., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To evaluate the nutritional status and early nutritional intake of infants with univentricular congenital heart disease., Study Design: The included infants underwent a Norwood procedure or hybrid intervention (stage 1) within the first 6 weeks of life, between January 2014 and January 2019, at Children's Health Ireland at Crumlin. Demographic, anthropometric, nutritional intake, and morbidity data were collected., Results: Data were collected on 90 infants and 1886 neonatal admission days. There was a significant drop in mean weight-for-age z-score (WAZ) between measurements at birth, -0.01 and on discharge post stage 1 surgery -1.45 (P < .01). On hospital discharge (median hospital stay, 25 days) 32% of infants had a WAZ <-2 and 11% had a WAZ <-3. Pre-stage 1, 26% received trophic feeds and 39% received parenteral nutrition. Basal metabolic requirements and target caloric intake (120 kcal/kg) were met on 56% and 13% of admission days, respectively. Infants referred to a dietitian had a shorter time to any form of nutrition support, enteral feeds, and target caloric intake (P < .001, P = .016, and P = .048, respectively). At stage 3 (Fontan) surgery, 15% of infants were classified as stunted (length-for-age z-score [LAZ] <-2)., Conclusions: The greatest decline in nutritional status occurs in the neonatal period, followed by significant growth stunting by the time of the Fontan procedure. Early involvement of dietitians is critical in the care of this nutritionally fragile group. With the currently low rate of preoperative nutritional support, there may be opportunities to improve intake at this critical stage., (Copyright © 2021 Elsevier Inc. All rights reserved.)

As data and recommendations regarding antibiotic prophylaxis in dermatologic surgery vary, we tried to describe the effect of antibiotic prophylaxis (AP) in Mohs micrographic surgery (MMS) on infective endocarditis, prosthetic joint infection, and surgical site infection using a single-institution retrospective cohort study of antibiotic use (pre-/intra-operative, post-operative or none) among 2,364 patient encouters treated with MMS. Bivariate logistic regression was evaluated for associations between patient and operative characteristics, antibiotic use, and infectious complications. 85.8% of patients received no AP, 10.0% received post-operative AP, and 4.1% received pre-/intra-operative AP. The overall surgical site infection (SSI) rate was 1.3%. SSI did not differ between patients who received pre-/intra-operative prophylaxis, post-operative prophylaxis or no antibiotics. One patient receiving pre-/intra-operative prophylaxis developed SSI. Repairs involving porcine xenografts and interpolation/pedicle flaps were associated with increased SSI. In addition, there were no patients who post-operatively experienced an infected joint or infective endocarditis. Limitations include selection bias, use of observational retrospective data, low infection rates, single institution analysis, and possible omission of explanatory variables or confounders. There was no difference in rates of SSI when comparing MMS patients who received pre-/intra-operative, post-operative or no AP. There were no cases of infective endocarditis or infected prosthetic joint., (© 2020. Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Red blood cell transfusions are common in patients undergoing gastrointestinal cancer surgery. Yet, to adequately balance their risks and benefits, clinicians must understand how transfusions may affect long-term outcomes. We aimed to determine if perioperative red blood cell transfusions are associated with a higher risk of all-cause and cancer-specific death among patients who underwent gastrointestinal cancer resection., Method: We identified a population-based cohort of patients who underwent gastrointestinal cancer resection in Ontario, Canada (2007-2019). All-cause death was compared between transfused and nontransfused patients using Cox proportional hazards regression, while cancer-specific death was compared with competing risk regression., Result: A total of 74,962 patients (mean age, 67.7 years; 55.4% male; 79.7% colorectal cancer) had gastrointestinal cancer surgery during the study period; 20.8% received perioperative red blood cell transfusions. Patients who received red blood cell transfusions had increased hazards of all-cause and cancer-specific death relative to patients who did not (hazard ratio: 1.39, 95% confidence interval 1.34-1.44; cause-specific hazard ratio: 1.36, 1.30-1.43). The adjusted risk of all-cause death was higher in early follow-up intervals (3-6 months postoperatively) but remained elevated in each interval over 5 years. The association persisted after restricting to patients without postoperative complications or bleeding and was robust to unmeasured confounding., Conclusion: Red blood cell transfusion among patients with gastrointestinal cancer is associated with increased all-cause death. This was observed long beyond the immediate postoperative period and independent of short-term postoperative morbidity and mortality. These findings should help clinicians balance the risks and benefits of transfusion before well-designed trials are conducted in this patient population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: To assess the quality of care for patients with diabetes in Queensland hospitals, including blood glucose control, rates of hospital-acquired harm, the incidence of insulin prescription and management errors, and appropriate foot and peri-operative care., Design, Setting: Cross-sectional audit of 27 public hospitals in Queensland: four of five tertiary/quaternary referral centres, four of seven large regional or outer metropolitan hospitals, seven of 13 smaller outer metropolitan or small regional hospitals, and 12 of 88 hospitals in rural or remote locations., Participants: 850 adult inpatients with diabetes mellitus in medical, surgical, mental health, high dependency, or intensive care wards., Results: Twenty-seven of 115 public hospitals that admit acute inpatients participated in the audit, including 4175 of 6652 eligible acute hospital beds in Queensland. A total of 1003 patients had diabetes (24%), and data were collected for 850 (85%). Their mean age was 65.9 years (SD, 15.1 years), 357 were women (42%), and their mean HbA 1c level was 66 mmol/mol (SD, 26 mmol/mol). Rates of good diabetes days (appropriate monitoring, no more than one blood glucose measurement greater than 10 mmol/L, and none below 5 mmol/L) were low in patients with type 1 diabetes (22.1 per 100 patient-days) or type 2 diabetes treated with insulin (40.1 per 100 patient-days); hypoglycaemia rates were high for patients with type 1 diabetes mellitus (24.1 episodes per 100 patient-days). One or more medication errors were identified for 201 patients (32%), including insulin prescribing errors for 127 patients (39%). Four patients with type 1 diabetes experienced diabetic ketoacidosis in hospital (8%); 121 patients (14%) met the criteria for review by a specialist diabetes team but were not reviewed by any diabetes specialist (medical, nursing, allied health)., Conclusions: We identified several deficits in inpatient diabetes management in Queensland, including high rates of medication error and hospital-acquired harm and low rates of appropriate glycaemic control, particularly for patients treated with insulin. These deficits require attention, and ongoing evaluation of outcomes is necessary., (© 2021 AMPCo Pty Ltd.)

Objective: To determine surgical site infection and urinary tract infection (UTI) rates in the setting of urethroplasty. Given significant variation in the utilization of antibiotics, there is an opportunity to improve antibiotic stewardship. This study aims to elucidate the rate of both UTI and surgical site infection after urethroplasty on a standardized perioperative antibiotic regimen, and to obtain patient and operative characteristics that may predict infection., Methods: We prospectively treated 390 patients undergoing urethroplasty at 11 centers with a standardized perioperative antibiotic protocol. Patients had a urine culture or urine analysis within 3 weeks of surgery. After surgery, patients were discharged with an indwelling catheter, removed per usual surgeon practice. All were given nitrofurantoin from discharge until catheter removal. Logistic regression analyses were performed to determine the correlation between patient characteristics or operative categories with post-operative infection., Results: The rates of postoperative UTI and wound infection within 30 days were 6.7% and 4.1%, respectively. On multivariate analysis of demographics, comorbidities, and stricture characteristics and repair, only preoperative UTI (P = .012), history of cardiovascular disease (P = .015), and performing a membranous urethroplasty (0.018) were significant predictors of a UTI within 30 days postoperatively. Location of repair nor graft use increased the risk of UTI. There were no factors predictive of postoperative wound infection., Conclusion: A standardized antibiotic protocol was created to narrow and limit excess antibiotic use. This protocol, with clear definitions of UTI and wound infection, allowed determination of accurate infection rates in urethroplasties. Preoperative UTI, even when properly treated, increases the risk of postoperative UTI., (Copyright © 2020. Published by Elsevier Inc.)

Competing Interests: The authors have no conflicts of interests to disclose.

The clinical course of COVID-19 in pediatric solid organ transplant recipients remains ambiguous. Though preliminary experiences with adult transplant recipients have been published, literature centered on the pediatric population is limited. We herein report a multi-center, multi-organ cohort analysis of COVID-19-positive transplant recipients ≤ 18 years at time of transplant. Data were collected via institutions' respective electronic medical record systems. Local review boards approved this cross-institutional study. Among 5 transplant centers, 26 patients (62% male) were reviewed with a median age of 8 years. Six were heart recipients, 8 kidney, 10 liver, and 2 lung. Presenting symptoms included cough (n = 12 (46%)), fever (n = 9 (35%)), dry/sore throat (n = 3 (12%)), rhinorrhea (n = 3 (12%)), anosmia (n = 2 (8%)), chest pain (n = 2 (8%)), diarrhea (n = 2 (8%)), dyspnea (n = 1 (4%)), and headache (n = 1 (4%)). Six patients (23%) were asymptomatic. No patient required supplemental oxygen, intubation, or ECMO. Eight patients (31%) were hospitalized at time of diagnosis, 3 of whom were already admitted for unrelated problems. Post-transplant immunosuppression was reduced for only 2 patients (8%). All symptomatic patients recovered within 7 days. Our multi-institutional experience suggests the prognoses of pediatric transplant recipients infected with COVID-19 may mirror those of immunocompetent children, with infrequent hospitalization and minimal treatment, if any, required., (© 2020 Wiley Periodicals LLC.)

Objective: This study aimed to investigate the impact of chronic kidney disease (CKD) and the delivery of nephrology care on outcomes of carotid endarterectomy (CEA)., Methods: This was a single centre, retrospective observational study. Between January 2007 and December 2014, 675 CEAs performed on 613 patients were stratified by pre-operative estimated glomerular filtration rate (eGFR) values (CKD [eGFR < 60 mL/min/1.73m 2 ] and non-CKD [eGFR ≥ 60 mL/min/1.73m 2 ] groups) for retrospective analysis. The study outcomes included the occurrence of major adverse cardiovascular events (MACEs), defined as fatal or non-fatal stroke, myocardial infarction, or all cause mortality, during the peri-operative period and within four years after CEA., Results: The CKD group consisted of 112 CEAs (16.6%), and the non-CKD group consisted of 563 CEAs (83.4%). The MACE incidence was higher among patients with CKD compared with non-CKD patients during the peri-operative period (4.5% vs. 1.8%; p = .086) and within four years after CEA (17.9% vs. 11.5%; p = .066), with a non-statistically significant trend. In a subgroup analysis of patients with CKD under nephrology care (63/112, 56.3%; with better controlled risk factors and tighter medical surveillance by a nephrologist), patients with CKD without nephrology care (49/112, 43.8%), and non-CKD patients, the risk of both peri-operative (4.1% vs. 0.4%; p = .037) and four year post-operative (20.4% vs. 7.3%; p = .004) all cause mortality was statistically significantly higher among patients with CKD without nephrology care compared with non-CKD patients. However, there were no statistically significant differences between patients with CKD who received nephrology care and non-CKD patients in peri-operative and four year post-operative MACE occurrence, both in terms of the composite MACE outcome and the individual MACE components., Conclusion: Despite the higher risk of peri-operative and four year MACE after CEA among patients with CKD, and the statistically significantly higher peri-operative and four year post-operative all cause mortality rates among patients with CKD without nephrology care, patients with CKD under nephrology care had similar outcomes to non-CKD patients., (Copyright © 2021 European Society for Vascular Surgery. Published by Elsevier B.V. All rights reserved.)

Aim: To determine current practice regarding the diabetes management of people undergoing cardiac surgery in the UK., Methods: We conducted an online survey of UK cardiothoracic surgeons. All cardiothoracic surgeons listed in the Society of Cardiothoracic Surgery membership directory were invited to participate. The survey, compiled using SurveyMonkey software, comprised 15 closed and open-ended questions about the management of people with diabetes pre- and peri-operatively., Results: Sixty-two cardiothoracic surgeons from all 33 UK cardiac centres completed the survey. Of these, 44% responded that they routinely measure HbA 1c preoperatively for all patients, 19% had an HbA 1c threshold above which they would not operate and 21% currently undertake a point-of-care HbA 1c measurement during the cardiothoracic outpatient visit. A total of 74% of respondents reported that it was 'easy' or 'very easy' to obtain a diabetes team review; diabetes nurse specialists were the members of the diabetes team working most closely with cardiac surgeons. Up to a third of the surgeons did not provide physical activity recommendations prior to admission and over 80% did not have a different preoperative or surgical diabetes protocol. Inconsistency in the responses within centres suggests that differences in practice may depend on individual surgeons rather than local policy., Conclusions: The study demonstrates there is only limited peri-operative management of diabetes in people undergoing cardiac surgery in the UK. There is an opportunity for greater involvement of the diabetes specialist team both before and during admission for surgery to improve outcomes. (Trial registration: ISRCTN10170306)., (© 2020 Diabetes UK.)

Background/aim: Since January 2020, coronavirus disease (COVID-19) cases have been confirmed in Japan, and the number of patients with COVID-19 has been increasing. Two emergency declarations have been made previously and one is currently in effect. Based on our experience of a situation that could affect cancer treatment, this study retrospectively examined the correlation between perioperative anticancer therapy and COVID-19 incidence in patients with breast cancer., Patients and Methods: Patients who underwent perioperative anticancer therapy for breast cancer at our hospital from February 2020 to February 2021 were included in this study. The presence or absence of COVID-19, timing of anticancer drug initiation, and clinical data were collected., Results: No cases of COVID-19 were diagnosed in patients receiving perioperative anticancer therapy at our hospital., Conclusion: Regimen modification, active use of supportive care, and patient lifestyle were factors reducing the incidence of COVID-19., (Copyright © 2021 International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: The aim of this study is to examine the interaction between preoperative anemia and perioperative transfusions with postoperative morbidity and mortality among patients undergoing gastrectomy for cancer., Materials and Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2016. Restricted cubic splines modeled the nonlinear relationship between preoperative hematocrit (Hct) and 30-day overall morbidity, sepsis, and mortality. Preoperative Hct was categorized based on cut points for the three models. Multiple regression modeling examined the interactive effect of preoperative anemia and postoperative transfusion on surgical outcomes., Results: Among 9936 included patients, complication incidence was 38.9% (sepsis 12.7%; mortality 6.0%). Preoperative Hct cut points were identified at 29 and 42. Hct <29 was associated with higher risk of morbidity (OR 2.47, 95%CI 2.10-2.93). Postoperative transfusion was associated with lower risk of morbidity for Hct <29 (OR 0.56, 95%CI 0.43-0.73) but increased risk between 29 and 42 (OR 1.59, 95%CI 1.21-2.08). Similar relationships were found for sepsis and mortality., Conclusions: Preoperative Hct <29 is associated with an increased risk of surgical complications after gastrectomy for cancer and perioperative transfusions appear to be beneficial for Hct <29 only. There may be a role for better optimization of red cell mass among high-risk patients before gastrectomy for cancer., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The United States population is aging, and the number of older adults requiring operative care is increasing at a rapid rate. In order to address this issue, the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society created best practice guidelines surrounding optimal perioperative care for the older adult surgical patient. This study aimed to determine the documented compliance with these guidelines at a single institution., Methods: A retrospective chart review was performed on 86 older adults undergoing elective, inpatient coronary artery bypass graft, prostatectomy, or colectomy over a 2-year period (1/2016-12/2017) at a single Veterans Affairs institution. The primary outcome was compliance with the 38 measures from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society Best Practice Guidelines. The secondary outcome was postoperative (including geriatric-specific) complications., Results: The mean reported compliance across all measures was 41% ± 4%. Of 38 analyzed measures, compliance for 10 measures was achieved for 0 patients, and only 1 patient for 7 measures. There was variance in compliance by phase of care (P < .05) with a high of 56% ± 8% (immediate preoperative phase of care) and a low of 35% ± 4% (intraoperative phase of care)., Conclusion: Overall reported compliance with the Best Practice Guidelines of the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society is low (41%) at this institution. This study identifies a need to improve the care provided to the vulnerable population of older adults undergoing an operation. Future work is needed to understand barriers for implementation and how compliance relates to outcomes., (Published by Elsevier Inc.)

The aim of this study was to assess whether transversus abdominis plane (TAP) blocks can be utilized to decrease patient pain scores and narcotic use during the first 24 h following robot-assisted laparoscopic prostatectomy (RALP). 100 patients received a TAP block with a mixture of 1.3% liposomal bupivacaine, 0.5% Marcaine and 0.9% NaCl prior to RALP. This was in addition to an already established pain management regiment, which included preoperative PO acetaminophen (650 mg), celecoxib (200 mg), and tolterodine ER (4 mg). These patients were prospectively followed and then retrospectively compared to a 1:1 propensity matched group of 100 patients that did not receive a TAP but did receive the preoperative PO medications. Pain scores were assessed on a scale from 1-10 in the PACU, as well as the surgical floor at 8, 16, and 24-h post-surgery. Intra-/post-operative narcotic use and time to ambulation following arrival to the surgical floor were also analyzed. Patient receiving TAP blocks had immediate post-op pain scores of 2.23 vs 4.26 for those not receiving TAP blocks (p = 0.000). The pain scores at 8, 16, and 24 h for TAP patients were 2.68, 2.62, and 2.62 as compared to 2.89, 2.87, and 3.36 for non-TAP patients. The difference was statistically significant for immediate and 24-h pain scores (p = 0.000, 0.001, respectively). On average, TAP block patients ambulated faster than non-TAP patients, 2.68 vs 4.91 h (p = 0.000). Intra-operative narcotic use was decreased in the TAP group for each of the opioids that were used: fentanyl 177.5 vs 205mcg (p = 0.001), morphine 5.5 vs 10 mg (p = 0.000), and hydromorphone 0.75 vs 1.75 mg (p = 0.001). Narcotic usage in the PACU was limited to hydromorphone and TAP patients used 0.7 mg compared to 1.36 mg (p = 0.003) for non-TAP patients. Oral oxycodone/acetaminophen (5 mg/325 mg) was used for pain control on the surgical floor and on average TAP patients received less, 2.4 vs 5 tabs (p = 0.000). Average time to perform the TAP block was 3.5 min and total OR time for TAP vs non-TAP patients was 107.41 vs 106.58 min (p = 0.386). TAP blocks as part of a perioperative pain management protocol can be utilized during RALPs to decrease patient pain scores at two different time intervals, immediately post-operative and 24 h after surgery. Patients also ambulate sooner following surgery and require a decreased amount of narcotics during the intra-operative and post-operative periods. TAP blocks are quick, effective, and do not add a significant amount of OR time to RALPs.

Background: Direct oral anticoagulants (DOACs), such as apixaban, rivaroxaban, and dabigatran, are increasingly being used to provide prophylaxis and treatment for arterial and venous thromboembolism. Multiple procedural subspecialties have implemented guidelines detailing time frames for perioperative DOAC interruption; however, the impact of perioperative DOAC interruption in patients undergoing dermatologic surgery is currently unknown, and evidence-based guidelines are lacking., Objective: To assess the 30-day postoperative rate of thrombotic complications (ischemic stroke, transient ischemic attack, systemic embolism, deep vein thrombosis [DVT] and pulmonary embolism) in patients with nonvalvular atrial fibrillation (AF) or a history of DVT who underwent perioperative DOAC interruption during dermatologic surgery., Methods: A retrospective medical record review was performed of all patients with AF or a history of DVT who underwent perioperative DOAC interruption during dermatologic surgery at Advanced Dermatologic Surgery and the University of Kansas Medical Center between January 1, 2016, and August 31, 2020., Results: Among 806 operations, comprising 750 Mohs micrographic operations (93.1%) and 56 excisions (6.9%), 1 patient (0.14% of patients with AF) sustained a transient ischemic attack and 2 patients (0.25% of all patients) sustained minor bleeding complications during the 30-day postoperative period., Conclusion: Perioperative DOAC interruption appears to be safe and efficacious in dermatologic surgery., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Study Objective: The primary objective was to introduce an intraoperative blood conservation bundle (BCB) checklist into clinical practice and assess its impact on perioperative blood transfusion rates during myomectomy., Design: Prospective cohort study with retrospective control group., Setting: A Canadian tertiary-care teaching hospital., Patients: One hundred and eighty-six women who underwent myomectomy., Interventions: The BCB is a physical checklist attached to the patient chart and consists of evidence-based medical and surgical interventions to reduce intraoperative blood loss. It was introduced in October 2018, and data were collected prospectively during a 12-month period for all open, robotic, and laparoscopic myomectomies at our institution. The primary outcome was the perioperative transfusion rate, and the secondary outcomes included estimated intraoperative blood loss, perioperative complications, readmissions, and BCB usage rates. Data were compared with those of a historic control group for a 24-month period before the BCB introduction., Measurements and Main Results: In the pre-BCB period, 134 myomectomies (90 open, 31 robotic, and 13 laparoscopic) were performed, and during our study period, 52 myomectomies (33 open, 10 robotic, and 9 laparoscopic) were performed. There was a decrease in transfusion rate from 15.7% (21/134) to 7.7% (4/52) after introduction of the BCB; however, this was not significant (p = .152). The mean estimated blood loss was lower postintervention (491 mL ± 440 mL vs 350 mL ± 255 mL; p <.05) as was the mean delta hemoglobin (-28 g/L ± 13.0 g/L vs -23 g/L ± 11.4g/L; p <.05]. The checklist was used in 92.3% of cases (48/52). There were no differences in intraoperative or postoperative complications or readmission rates., Conclusion: Best practice care bundles can improve knowledge translation of guidelines into care delivery. The introduction of the BCB was successful in reducing intraoperative blood loss during myomectomy at our institution. The BCB is a simple, effective tool that can be easily adopted by gynecologic surgeons to guide intraoperative decision-making during myomectomy., (Copyright © 2020 AAGL. Published by Elsevier Inc. All rights reserved.)

Off-pump coronary artery bypass grafting (OPCABG) may be performed on patients with high surgical risk who are poor candidates for traditional mechanical circulatory support. Hemodynamic support with micro-axial mechanical circulatory devices has been performed with limited but promising results.We report a case of a 66-year-old male with multiple comorbidities and low cardiac output undergoing OPCABG. Impella CP device was deployed for "in-pump" support during surgical coronary revascularization resulting in intraoperative stability and uncomplicated post-operative recovery.Previous reports have described the use of the Impella Recover LP 5.0 device for use during OPCABG. We describe the successful and safe perioperative use of the Impella CP device. Despite lower flow rates, adequate support was achieved and the transfemoral cannulation and smaller outer diameter than the Impella 5.0 device may decrease the risk of complications and expedite recovery. Further research will be necessary to determine the optimal perioperative hemodynamic support strategy to offer hemodynamically unstable, high, and prohibitive risk patients.

The ACERTO project is a multimodal perioperative care protocol. Implemented in 2005, the project in the last 15 years has disseminated the idea of a modern perioperative care protocol, based on evidence and with interdisciplinary team work. Dozens of published studies, using the protocol, have shown benefits such as reduced hospital stay, postoperative complications and hospital costs. Disseminated in Brazil, the project is supported by the Brazilian College of Surgeons and the Brazilian Society of Parenteral and Enteral Nutrition, among others. This article compiles publications by the authors who belong to the CNPq research group "Acerto em Nutrição e Cirurgia", refers to the experience of other national authors in various surgical specialties, and finally outlines the evolution of the ACERTO project in the timeline.

Background: Codeine and tramadol are commonly used analgesics in surgery. In 2013, the Food and Drug Administration (FDA) issued a contraindication to the use of codeine in tonsillectomy and adenoidectomy patients aged below 18 y. This warning was expanded in April 2017 to include tramadol and all children aged below 12 y. We sought to describe the prescribing of codeine and tramadol to contraindicated populations in Wisconsin before and after the release of the expanded FDA warning., Materials and Methods: Using a statewide Wisconsin claims database, we identified common pediatric ambulatory surgical procedures across the specialties of otolaryngology, urology, general surgery, orthopedics, and ophthalmology. For these procedures, we examined the rates of perioperative codeine and tramadol prescription fills and change in prescribing after the FDA contraindication., Results: Surgeons in all of the specialties studied continued to prescribe codeine to pediatric patients after the contraindication, but tramadol was rarely prescribed. Procedures with relatively high rates of codeine fills were strabismus repair (65% of opioid fills), circumcision >1 yo (22%), and laparoscopic appendectomy (15%). Codeine fills significantly declined after the contraindication to 6% for circumcision >1 yo and 5% for orchiopexy and inguinal hernia repair. Otolaryngology, which was subject to the 2013 codeine contraindication, has low rates of codeine fills (under 2.5%) for the whole period studied. Codeine prescribing for strabismus repair showed no significant decline., Conclusions: Codeine, and to a lesser extent tramadol, continue to be prescribed to contraindicated populations of children. This represents a target for future de-implementation interventions., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The protection of healthcare workers from the risk of nosocomial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is a paramount concern. SARS-CoV-2 is likely to remain endemic and measures to protect healthcare workers against nosocomial infection will need to be maintained. This review aims to inform the assessment and management of the risk of SARS-CoV-2 transmission to healthcare workers involved in elective peri-operative care. In the absence of data specifically related to the risk of SARS-CoV-2 transmission in the peri-operative setting, we explore the evidence-base that exists regarding modes of viral transmission, historical evidence for the risk associated with aerosol-generating procedures and contemporaneous data from the COVID-19 pandemic. We identify a significant lack of data regarding the risk of transmission in the management of elective surgical patients, highlighting the urgent need for further research., (© 2020 Association of Anaesthetists.)

Background: This study aimed to investigate the association between perioperative antiplatelet (anti-PLT) therapy and 90-d mortality after elective noncardiac surgery., Materials and Methods: This retrospective cohort study analyzed the medical records of adult patients aged 18 y and older who were admitted to a single tertiary academic hospital between January 1, 2012 and December 31, 2018 for planned elective noncardiac surgery. All patients with a history of coronary artery stent insertion before the day of surgery were excluded from the analysis. Propensity score matching and conditional logistic regression analysis were used for statistical analysis., Results: After propensity score matching, a total of 24,710 patients (12,355 in each group) were included in the final analysis. Ninety-day mortalities in the anti-PLT and non-anti-PLT groups were 0.9% (107/12,355) and 1.2% (143/12,355), respectively. The anti-PLT group showed significantly lower odds for 90-d mortality (by 27%) than the non-anti-PLT group (odds ratio, 0.73; 95% confidence interval, 0.55-0.95; P = 0.017). In the sensitivity analysis of the anti-PLT group classified according to the drug type and combination, the aspirin and clopidogrel subgroups significantly showed 23% and 41% lower odds for 90-d mortality compared with the non-anti-PLT group, respectively. The dual anti-PLT groups showed no significant difference in 90-d mortality (P = 0.658)., Conclusions: Perioperative anti-PLT therapy (aspirin, clopidogrel, or dual anti-PLT therapy) was associated with lower 90-d mortality after elective noncardiac surgery in adult surgical patients without a coronary stent. This association was most evident in patients on a monotherapy of aspirin or clopidogrel., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The coronavirus disease 2019 (COVID-19) pandemic has resulted in reduced performance of elective surgeries and procedures at medical centers across the United States. Awareness of the prevalence of asymptomatic disease is critical for guiding safe approaches to operative/procedural services. As COVID-19 polymerase chain reaction (PCR) testing has been limited largely to symptomatic patients, health care workers, or to those in communal care centers, data regarding asymptomatic viral disease carriage are limited., Methods: In this retrospective observational case series evaluating UCLA Health patients enrolled in pre-operative/pre-procedure protocol COVID-19 reverse transcriptase (RT)-PCR testing between April 7, 2020 and May 21, 2020, we determine the prevalence of COVID-19 infection in asymptomatic patients scheduled for surgeries and procedures., Results: Primary outcomes include the prevalence of COVID-19 infection in this asymptomatic population. Secondary data analysis includes overall population testing results and population demographics. Eighteen of 4,751 (0.38%) patients scheduled for upcoming surgeries and high-risk procedures had abnormal (positive/inconclusive) COVID-19 RT-PCR testing results. Six of 18 patients were confirmed asymptomatic and had positive test results. Four of 18 were confirmed asymptomtic and had inconclusive results. Eight of 18 had positive results in the setting of recent symptoms or known COVID-19 infection. The prevalence of asymptomatic COVID-19 infection was 0.13%. More than 90% of patients had residential addresses within a 67-mile geographic radius of our medical center, the median age was 58, and there was equal male/female distribution., Conclusion: These data demonstrating low levels (0.13% prevalence) of COVID-19 infection in an asymptomatic population of patients undergoing scheduled surgeries/procedures in a large urban area have helped to inform perioperative protocols during the COVID-19 pandemic. Testing protocols like ours may prove valuable for other health systems in their approaches to safe procedural practices during COVID-19., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: There is inadequate high-quality evidence on thromboprophylaxis for patients undergoing surgery for abdominopelvic cancer. We surveyed physicians who treat patients with abdominopelvic cancer to determine current thromboprophylaxis practice patterns and to determine where research is needed., Methods: We created an online survey with questions on thromboprophylaxis topics, including type of thromboprophylaxis used, timing of initial thromboprophylaxis dose, use of thromboprophylaxis during chemotherapy, use of extended-duration thromboprophylaxis and areas for future research. The survey questions were reviewed by external content experts to ensure they were appropriate and relevant. Surgeons, thrombosis experts and medical oncologists who manage patients with abdominopelvic cancers at 1 large Canadian academic centre were invited to complete the survey between January and April 2019., Results: Of the 57 physicians invited, 42 (74%) completed the survey, including 27 surgeons (response rate 79%), 9 thrombosis experts (response rate 75%) and 6 medical oncologists (response rate 55%). Most surgeons (22 [82%]) reported using mechanical thromboprophylaxis, whereas only 1 thrombosis expert (11%) recommended mechanical thromboprophylaxis. There was substantial variability in the timing of the initial dose of thromboprophylaxis, with 9/10 urologists (90%) and all 7 general surgeons giving the first dose intraoperatively, and three-quarters of thoracic surgeons (3/4 [75%]), gynecologists (3/4 [75%]) and thrombosis experts (7/9 [78%]) starting thromboprophylaxis after surgery. All medical oncologists believed chemotherapy increases the risk of venous thromboembolism, but 4 (67%) reported that they do not routinely prescribe thromboprophylaxis owing to bleeding concerns. Most respondents (35/38 [92%]) felt there was a need for more research on thromboprophylaxis and indicated willingness to participate in future clinical trials., Conclusion: Variability exists in contemporary thromboprophylaxis practice patterns among physicians treating patients with abdominopelvic cancer. Future research is needed to standardize care and improve outcomes for patients., Competing Interests: Marc Carrier reports grant funding from BristolMyers Squibb, LEO Pharma and Pfizer, and consulting fees from Bayer, Bristol-Myers Squibb, LEO Pharma, Sanofi and Servier, outside the submitted work. Christopher Morash participated in an advisory board run by Sanofi, outside the submitted work. Luke Lavallée reports a quality improvement grant from Sanofi and advisory board participation for AbbVie, Bayer, Sanofi and Ferring, outside the submitted work. No other competing interests were declared., (© 2020 Joule Inc. or its licensors.)

Background: Overall, 10-15% of hospitalized children are undernourished. The present study focuses on pediatric surgical wards. We assessed the impact of undernutrition upon admission on the weight-for-height Z-score (Z-WFH) during hospitalization for surgery. Secondary aims were to investigate the influence of associated factors and to report on the use of nutritional support., Methods: All children hospitalized for a surgical procedure between July 2015 and March 2016 were included in this monocentric, prospective study. Children were divided into two groups: whether the Z-WFH upon admission was below -2 standard deviations (undernourished) or not (not undernourished)., Results: A total of 161 of 278 eligible children were included; 27 were undernourished (17%). The change in Z-WFH during hospitalization was greater in undernourished children (0.31±0.11 vs. -0.05±0.05, P=0.005). Of undernourished children, 49% recovered a Z-WFH above -2 SD during hospitalization. There was no difference between undernourished children and not undernourished children regarding age, length of hospital stay, pre- and post-operative duration of nil per os, duration of surgical procedure, ASA score, emergency level of the surgical procedure, and enteral/parenteral nutrition., Conclusion: Our data suggest that the Z-WFH of undernourished children upon admission improved during hospitalization., (Copyright © 2020 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

Background In the PAUSE (Perioperative Anticoagulant Use for Surgery Evaluation) Study, a simple, standardized, perioperative interruption strategy was provided for patients with nonvalvular atrial fibrillation taking direct oral anticoagulants (DOACs). Our objective was to define the factors associated with perioperative bleeding. Methods and Results We analyzed bleeding as the composite of major and clinically relevant nonmajor bleeding. Putative predictors of bleeding, and preoperative DOAC level were prospectively collected during recruitment. We used stratified logistic regression models for analysis. All statistical analyses were performed in R version 3.6.0. There were 3007 patients requiring perioperative DOAC interruption. More than one third of the included patients underwent a high bleeding risk procedure. The 30-day rates of major and clinically relevant nonmajor bleeding were 3.02% in apixaban (n=1257), 2.84% in dabigatran (n=668), and 4.16% for rivaroxaban (n=1082). Multivariate analysis stratified by region found more bleeding for hypertension (odds ratio [OR], 1.79; 95% CI 1.07-2.99; P =0.027), and prior bleeding (OR, 1.71; 95% CI, 1.08-2.71; P =0.021). Surgical bleed risk classification (high- versus low-risk) as a predictor of bleeding was only significant in the univariate analysis. The prediction model for major and clinically relevant nonmajor bleeding had an area under the curve of 0.71, and the preoperative DOAC level did not improve the area under the curve of the model. Conclusions In patients treated with DOACs who required an elective surgery/procedure and were managed with standardized DOAC interruption and resumption, there we did not find reversible risk factors for bleeding, suggesting that adjustment of the PAUSE management protocol to mitigate against bleeding is not needed.

Introduction: This paper examines the pain management, from surgery to specialist rehabilitation, of the first seven military transfemoral amputee patients treated in the UK with femoral osseointegration. All the patients had sustained complex ballistic injuries on the battlefield. The patients were characterised by long-standing problems with functional rehabilitation due to limitations with conventional prostheses, including stump soft tissue issues and impaired biomechanics., Methods: A prospective service investigation was undertaken to evaluate the effectiveness of the pain management of patients undergoing osseointegration. Data were collected by daily direct patient contact, supplemented by a focused review of perioperative and rehabilitation case notes. Physiological and medication details were recorded with specific reference to systemic and regional analgesia and the impact of postoperative complications, including infection and accidental injury., Results: Seven patients underwent femoral osseointegration and were followed up for a period of up to 3 years following surgery. The perioperative recovery was associated with significant escalation of analgesic requirements. Postoperative systemic inflammatory response syndrome was identified in six patients, with wound infection persisting in some cases into the rehabilitation phase. Three patients suffered femoral fractures following accidental injuries secondary to increased mobilisation following surgery., Conclusions: Successful surgical outcomes were achieved in a difficult patient cohort disadvantaged by previously restricted functional recovery from complex injuries. The importance of supporting the operative and recovery phases with a multidisciplinary pain service is emphasised. We offer this data and the lessons learnt to assist clinicians contemplating the establishment and service development of osseointegration services., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cardiac surgery accounts for 10-15% of blood transfusions in the US, despite benefits and calls of limiting its use. We sought to evaluate the impact of a restrictive transfusion protocol on blood use and clinical outcomes in patients undergoing isolated primary coronary artery bypass grafting (CABG)., Methods: Blood conservation measures, instituted in 2012, include preoperative optimization, intraoperative anesthesia, and pump fluid restriction with retrograde autologous priming and vacuum-assisted drainage, use of aminocaproic acid and cell saver, intra- and postoperative permissive anemia, and administration of iron and low-dose vasopressors if needed. Medical records of patients who underwent isolated primary CABG from 2009 to 2012 (group A; n = 375) and 2013 to 2016 (group B; n = 322) were compared., Results: CABG with grafting to three or four coronary arteries was performed in 262 (70%) and 222 (69%) patients and bilateral internal thoracic artery grafting in 202 (54%) and 196 (61%) patients in groups A and B, respectively. Mean preoperative and intraoperative hematocrit was 40.3% and 40.7%, 28.9% and 29.4% in groups A and B, respectively. Total blood transfusion was 24% and 6.5%, intraoperative transfusion 11% and 1.2%, and postoperative transfusion 20% and 5.6% (P < .0001 for all) in groups A and B, respectively. Median postoperative length of stay was 5.0 days in group A and 4.5 days in group B (P = .02), with no significant differences in mortality or morbidity., Conclusions: A restrictive transfusion protocol reduced blood transfusions and postoperative length of stay without adversely affecting outcomes following isolated primary CABG., (© 2020 Wiley Periodicals LLC.)

Background: Although surgical resection holds promise for curing pancreatic cancer, <20% of patients are suitable; however, early postoperative recurrence is common. Currently, radiographic examination is the primary method to determine whether pancreatic cancer has metastasized and to inform clinical staging before surgery. However, the method has a limited detection rate for micro-metastasis within the abdominal cavity; therefore, patients with advanced pancreatic cancer and existing micro-metastasis may receive unnecessary surgical treatment, delaying the timing of adjuvant chemotherapy and resulting in poor prognosis. Laparoscopic staging might be used as a supplement to detect micro-metastasis in patients with pancreatic cancer; however, there is no consistent standard to guide the use of this procedure. Therefore, it is necessary to conduct a trial to further explore the consistency and short-term and long-term efficacy of an intraoperative staging strategy for patients with radiographic non-metastasis., Methods/design: This is a single-center cross-sectional and follow-up study. Patients diagnosed with pancreatic cancer without metastasis by radiographic examination and histopathological biopsy, who received intraoperative restaging, will be enrolled. The total sample size required for the trial is approximately 125 patients from May 2020 to December 2022. First, radiographic examination staging will be used. Then, laparoscopic exploration will be performed for patients without definite metastatic lesions. Data collection will include preoperative blood examination, radiographic examination, surgical information, and postoperative recovery. The patients will undergo follow-up every 3 months after surgery until death. The primary endpoint is the metastasis-positive rate via laparoscopic exploration. The secondary endpoints are the consistency, sensitivity, and specificity of the intraoperative restaging strategy and radiographic examination, the incidence of postoperative complications within 30 days, the 6-month relapse-free survival rate, and perioperative indicators (total cost, hospital stay, length of surgery, and intraoperative blood loss)., Discussion: We are conducting the trial to explore the metastasis-positive rate of intraoperative restaging strategy for diagnosing pancreatic cancer micro-metastasis. This new intraoperative restaging strategy would help pancreatic cancer patients with potential micro-metastasis avoid receiving unnecessary resection, allow systemic treatment as early as possible, and improve the prognosis of patients.

Background: Enhanced recovery after surgery (ERAS) programs include multiple perioperative elements designed to achieve early recovery after surgery and a shorter length of stay (LOS) in hospital. The PROFAST trial aimed to expand the evidence base for implementing ERAS in advanced gynaecologic oncology surgery., Methods: This prospective, interventional randomised clinical trial enrolled women undergoing surgery for either suspected or diagnosed advanced ovarian cancer, at a reference hospital in gynaecologic oncology in Barcelona (Spain) and who were treated after either an ERAS protocol or conventional management (CM) protocol. All enrolled women who underwent cytoreductive surgery were included in the primary analysis. The primary outcome was reduction in LOS, and secondary outcomes were incidence and type of intraoperative and postoperative complications, rate of readmission and mortality within a 30-d follow-up period. This trial is registered at ClinicalTrials.gov, number NCT02172638., Findings: From June 2014 to March 2018, 110 women were recruited, of which eleven were excluded. The ERAS group comprised 50 patients, and the CM group, 49 patients. Both groups were comparable with respect to baseline characteristics and complexity of the cytoreductive surgery, with an overall medium/high Aletti surgical complexity score of 7.4. Overall compliance to the ERAS protocol was 92%. As compared with the patients in the CM group, patients in the ERAS group had a decreased median of LOS of two days (7 versus 9 days; p = 0.0099) and a decreased rate of readmission (6% versus 20%, p = 0.0334). No further significant differences were detected with respect to incidence of intraoperative or postoperative complications, severe (Clavien-Dindo grade IIIB-IV) complications, Comprehensive Complication Index, reoperation during primary stay, or mortality., Interpretation: Patients with advanced ovarian cancer in the ERAS program had a decreased LOS and decreased rate of readmission as compared with those in CM, with no increased morbidity or mortality. This study provides important evidence for the benefits of ERAS management even for gynaecologic surgeries of medium/high complexity and suggests that ERAS should be a standard practice for cytoreductive surgeries for peritoneal carcinomatosis., Competing Interests: Conflict of interest statement The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Perioperative blood transfusions in children are associated with patient morbidity and are often overutilized. In this study, we identify procedures most commonly associated with the use of red blood cells (RBC) in childrens surgery and develop risk-adjusted models for benchmarking., Methods: Data from the 2012-2015 National Surgical Quality Improvement Program-Pediatric participant use data files were used. CPT (Current Procedural Terminology) codes were grouped to identify the procedures where transfusions were allocated and associated patient demographics and comorbidities. Patients were stratified in two age groups (0-3 mo and 3 mo to 18 y), and a logistic regression model was developed for each age group., Results: Of 369,176 total cases, 21,410 (5.8%) were associated with a perioperative transfusion. 659 CPT codes were grouped in 207 clusters according to their similarities. The most common procedures associated with transfusion were arthrodesis for spinal deformity (n = 9533, 44.5%), followed by craniectomy for craniosynostosis (n = 1853, 8.7%). The logistic regression model for patients <3 mo included 18 variables and had excellent discriminatory performance (area under the curve 0.866). The model for patients ≥3 mo to 18 y had 21 variables and an area under the curve of 0.911., Conclusions: The majority of transfusions used in children's surgery are concentrated within a relatively few procedural groups. These findings can help centers in focusing blood optimization efforts on common surgeries with high transfusion rates. In addition, multiple preoperative factors have been built into a risk-adjusted model that can be used for benchmarking blood transfusions among hospitals., (Copyright © 2019 Elsevier Inc. All rights reserved.)