Intraoperative opioid and analgesic adjuvant administration practice patterns following implementation of an enhanced recovery after surgery protocol for laparoscopic donor nephrectomy

Study objectiveThe primary aim of this study is to understand how intraoperative medication administration patterns change in response to ERAS® protocol implementation for patients who underwent laparoscopic donor nephrectomy.DesignSingle-center, retrospective analysis of laparoscopic donor nephrectomy patients.SettingLarge tertiary academic medical center.PatientsWe divided all cases of laparoscopic donor nephrectomies (n = 929) over seven years into three approximately equal time periods: Pre-ERAS 1 (n = 317), Pre-ERAS 2 (n = 297) and Post-ERAS (n = 315).MeasurementsWe examined patient demographics, intraoperative opioid and non-opioid pain adjuvant administration, Post Anesthesia Recovery Unit (PACU) pain scores and opioid use as well as PACU and hospital lengths of stay (LOS).Main resultsSegmented regression analysis of interrupted time series was utilized to evaluate the association of ERAS protocol implementation with the amount of intraoperative opioid and non-opioid pain adjuvant use. In adherence to our institutional ERAS protocol, there was a significant reduction in intraoperative fentanyl use after ERAS protocol of −70.2μg (95% CI -106.0, −34.2, p < 0.001) and a significant increase in intraoperative hydromorphone use of 0.47 mg (95% CI 0.284, 0.655, p < 0.001). However, in contrary to our ERAS protocol, we found no significant change in odds of receiving IV acetaminophen OR 1.31 (95% CI 0.450, 3.76, p = 0.613) or IV ketorolac OR 1.65 (95% CI 0.804, 3.41, p = 0.172) after ERAS protocol implementation. We found a significant reduction in PACU opioid use of −9.68 Morphine Milligram Equivalents (MME) (95% CI -17.1, −2.31, p = 0.010) but no significant change in PACU initial pain score, PACU LOS and hospital LOS.ConclusionsWe examined intraoperative practice pattern changes by anesthesiologists in response to ERAS protocol implementation for laparoscopic donor nephrectomies. Our results suggest that there was a variable uptake of recommendations from ERAS protocol. While ERAS protocols are often studied as a bundle of best practice recommendations, understanding the variability of provider adherence represents an important future research direction for the ERAS initiative.     

Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-analysis

Introduction

Enhanced recovery after surgery (ERAS) programs have been developed to improve patient outcomes, accelerate recovery after surgery, and reduce healthcare costs. ERAS programs are a multimodal approach, with interventions during all stages of care. This meta-analysis examines the impact of ERAS programs on patient outcomes and recovery.

Methods

A comprehensive search of all published randomized control trials (RCTs) assessing the use of ERAS programs in surgical patients was conducted. Outcomes analyzed were length of stay (LOS), overall mortality, 30-day readmission rates, total costs, total complications, time to first flatus, and time to first bowel movement.

Results

Forty-two RCTs involving 5241 patients were analyzed. ERAS programs significantly reduced LOS, total complications, and total costs across all types of surgeries (p < 0.001). Return of gastrointestinal (GI) function was also significantly improved, as measured by earlier time to first flatus and time to first bowel movement, p < 0.001. There was no overall difference in mortality or 30-day readmission rates; however, 30-day readmission rates after upper GI surgeries nearly doubled with the use of ERAS programs (RR = 1.922; p = 0.019).

Conclusions

ERAS programs are associated with a significant reduction in LOS, total complications, total costs, as well as earlier return of GI function. Overall mortality and readmission rates remained similar, but there was a significant increase in 30-day readmission rates after upper GI surgeries. ERAS programs are effective and a valuable part in improving patient outcomes and accelerating recovery after surgery.

     

Current state of benefits of Enhanced Recovery After Surgery (ERAS) in spinal surgeries: A systematic review of the literature

IntroductionRecent years have been characterized by a great technological and clinical development in spine surgery. In particular, enhanced recovery after surgery (ERAS) programs, started to gain interest also in this surgical field. Here we tried to analyse the current state of art of ERAS technique in spine surgery.Material and methodA systematic review of the literature has been performed in order to find all the possible inclusions. Using the PRISMA guidelines, a search of the PubMed/Medline, Web of Science, Cochrane Reviews, Embase, Medline databases was conducted to identify all full-text articles in the English-language literature describing the use of ERAS programs or techniques for spine surgery in adult patients.ResultsOut of the 827 studies found, only 21 met the inclusion criteria has been retained to be included in the present study. The most frequently benefits of ERAS protocols were shorter hospitalisations (n = 15), and decreased complication rates (n = 8) lower postoperative pain scores (n = 4). These benefits were seen in the 3 main categories considered: lumbar spine surgeries, surgeries for correction of scoliosis or deformity, and surgeries of the cervical spine.ConclusionThere are an arising amount of data showing that the use of ERAS programs could be helpful in reducing the days of hospitalizations and the number of complications for certain spinal procedures and in a highly selected group of patients. Despite the large interest on the topic; there is an important lack of high level of scientific evidences. Because of that, there is the need to encourage the design and creation of new randomized clinical trials that will validate the present findings.     

Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review

IntroductionPostoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application.MethodsA literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL).ResultsTwelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n = 8). Non-opioid analgesia in ERAS improved postoperative pain control (n = 4) and decreased the duration of pain (n = 1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL.ConclusionImplementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.     

Are Patients Being Appropriately Selected for Same-Day Discharge Total Knee Arthroplasty?

BackgroundDecreased cost associated with same-day discharge (SDD) total knee arthroplasty (TKA) has led to an increased interest in this topic. The purpose of this study is to investigate whether there is a population of TKA patients in which SDD has similar rates of 30-day complications compared to patients discharged on postoperative day 1 or 2.MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2018, 6,327 TKA patients who had a SDD (length of stay [LOS] = 0) were matched to TKA patients who had an LOS of 1 or 2 days. All SDD patients were successfully matched 1:1 using the morbidity probability variable (a composite variable of demographics, comorbidities, and laboratory values). Patients were divided into quartiles based on their morbidity probability. Bivariate logistic regressions were then used to compare any complication and major complication rates in the SDD quartiles to the corresponding quartiles with an LOS of 1 or 2 days.ResultsWhen comparing the 1st quartiles (healthiest), there was no difference between the cohorts in any complication (odds ratio [OR] = 0.960, 95% CI 0.552-1.670, P = .866) and major complications (OR = 0.999, 95% CI = 0.448-2.231, P = .999). The same was observed in quartile 2 (any complications: OR = 1.161, 95% CI = 0.720-1.874, P = .540). Comparing the third quartiles, there was an increase in all complications with SDD (OR = 1.784, 95% CI = 1.125-2.829, P = .014), but no difference in major complications (OR = 1.635, 95% CI = 0.874-3.061, P = .124). Comparing the fourth quartiles (least healthy), there was an increase in all complications (OR = 1.384, 95% CI = 1.013-1.892, P = .042) and major complications (OR = 1.711, 95% CI = 1.048-2.793, P = .032) with SDD.ConclusionThe unhealthiest 50% of patients in this study who underwent SDD TKA were at an increased risk of having any complication, calling into question the current state of patient selection for SDD TKA.Level of EvidenceIII.     

Results of a colorectal enhanced recovery after surgery (ERAS) programme and a qualitative analysis of healthcare workers’ perspectives

BackgroundEnhanced recovery after surgery (ERAS) is a structured programme using a multimodal, evidence-based approach to improve post-operative outcomes. Successful implementation of ERAS can be challenging. We aimed to evaluate our initial experience with colorectal ERAS and explore the perspectives of specialist doctors and nurses.MethodsFrom 1 June 2017 to 31 December 2017, all patients who underwent elective colorectal resection and met the ERAS inclusion criteria at the Department of Colorectal Surgery, Singapore General Hospital, were included in the study. Short-term outcomes were compared between patients with >70% compliance to key ERAS components versus those with ≤70% compliance. Department staff were surveyed via questionnaire in July 2019.ResultsThree hundred and fifteen patients were included in study. >70% ERAS compliance rate was achieved in 84 patients (26.7%). A higher compliance rate resulted in a significantly shorter length of stay of 6 (IQR 5–8) days vs. 7 (IQR 6–9.5) days (p = 0.025) and lower readmission rate of 3.6% (n = 3) vs. 4.8% (n = 11) (p = 0.042), as well as a trend towards reduced complication rate of 15.4% (n = 13) vs. 22.0% (n = 51) and earlier return to gastrointestinal function. There was a 100% questionnaire response amongst all 12 colorectal surgeons and 5 colorectal resident nurse practitioners.ConclusionIncreased adherence to the components of ERAS results in better early outcomes and may have long-term benefits on survival. Effective communication and professional support for the ERAS multi-disciplinary team, as well as understanding healthcare workers’ concerns and addressing long-standing practices, is essential for successful implementation of the programme.     

Robotic lobectomy in children with severe bronchiectasis: A worthwhile new technology

Background/PurposeLobectomy is required in children affected by non-responsive, symptomatic, localized bronchiectasis, but inflammation makes thoracoscopy challenging. We present the first published series of robotic-assisted pulmonary lobectomy in children with bronchiectasis.MethodsRetrospective analysis of all consecutive patients who underwent pulmonary lobectomy for severe localized bronchiectasis (2014–2019) via thoracoscopic versus robotic lobectomy. Four 5 mm ports were used for thoracoscopy; a four-arm approach was used for robotic surgery (Da Vinci Surgical Xi System, Intuitive Surgical, California).ResultsEighteen children were operated (robotic resection, n = 7; thoracoscopy, n = 11) with infected congenital pulmonary malformation, primary ciliary dyskinesia, and post-viral infection. There were no conversions to open surgery with robotic surgery, but five with thoracoscopy. Total operative time was significantly longer with robotic versus thoracoscopic surgery (mean 247 ± 50 versus 152 ± 57 min, p = 0.008). There were no significant differences in perioperative complications, length of thoracic drainage, or total length of stay (mean 7 ± 2 versus 8 ± 3 days, respectively). No blood transfusions were required. Two thoracoscopic patients had a type-3 postoperative complication.ConclusionsPediatric robotic lung lobectomy is feasible and safe, with excellent visualization and bi-manual hand-wrist dissection – useful properties in difficult cases of infectious pathologies. However, instrumentation dimensions limit use in smaller thoraxes.     

Variability,outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis

Background/PurposeTo examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis.MethodsRetrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013–6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity.ResultsOverall PN utilization was 13.6%, ranging from 0–10.3% at low utilization hospitals (n = 452) and 10.3–32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS.ConclusionFollowing adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits.Level of Evidence Level III: Treatment study - Retrospective comparative study     

Enhanced Recovery After Surgery protocol for elderly gastric cancer patients: A prospective study for safety and efficacy

BackgroundEnhanced Recovery After Surgery (ERAS) has been used to improve surgical outcomes in recent years. However, its safety and efficacy in elderly patients with gastric cancer remain unclear. The aim of this study was to reveal the safety and efficacy of the ERAS protocol in elderly patients with gastric cancer.MethodsElderly gastric cancer patients (age≥70 years) who underwent gastrectomy were divided into the ERAS group and the conventional group. Postoperative complications, postoperative hospital stay, hospitalization expenses, and readmission rates were compared between the two groups.ResultsFrom December 2019 to January 2021, 100 eligible patients were enrolled in our study. All baseline data were balanced between the ERAS group and the conventional group. There was no significant difference in terms of complications (18% vs. 16%, P = 0.14) between the two groups. The most common complication was pneumonia. Four patients were observed in the conventional group and three patients in the ERAS group. The postoperative hospital stay was shorter in the ERAS group (8.2 vs. 10.4, P = 0.001).ConclusionsThe ERAS protocol could be safely used in elderly gastric cancer patients undergoing gastrectomy and shorten postoperative hospital stay.     

A Comparison of Open and Minimally Invasive Surgery for Hepatic and Pancreatic Resections Among the Medicare Population

Introduction

Minimally invasive surgery (MIS) has become standard of care for many gastrointestinal surgical procedures. Despite possible clinical benefits, MIS may be underutilized in some populations. The aim of this study was to access the utilization of MIS among Medicare patients undergoing hepatopancreatic procedures and define clinical outcomes, as well as costs, of minimally invasive techniques compared with the conventional open approach.

Methods

The Medicare Provider Analysis and Review (MEDPAR) Inpatient Files were reviewed to identify Medicare patients who underwent pancreatic and liver procedures between 2013 and 2015. Primary outcomes of the analysis included perioperative clinical outcomes such as rates of complications, index hospitalization length-of-stay (LOS), failure-to-rescue, rates, and causes of 90-day readmission, as well as 90-day mortality. Secondary outcomes were Medicare payments for index hospitalization and readmission. Multivariable logistic regression was used to investigate the impact of MIS on clinical outcomes and health expenditures.

Results

A total of 13,716 (90.6%) patients underwent open resection, while MIS was performed in 1424 (9.4%) patients. LOS was shorter among patients undergoing MIS (mean 7.3?±?SD 7.3) versus open (mean 9.3?±?SD 9.1) surgery (p?<?0.001). The incidence of perioperative complications was lower following MIS (open 25.5%, n?=?3492 vs. MIS 17.2%, n?=?245) (p?<?0.001). Rates of failure-to-rescue were similar among patients undergoing an open versus MIS pancreatic procedure (open 19.4%, n?=?271 vs. MIS 13.4%, n?=?17) (p?=?0.09). In contrast, 90-day readmission (open 31.1%, n?=?1630 vs. MIS 24.1%, n?=?201, p?<?0.001), as well as 90-day mortality (open 7.7%, n?=?404 vs. MIS 4.2%, n?=?35, p?<?0.001) were lower among patients undergoing pancreatic resections via an MIS approach. In contrast, failure-to-rescue and readmission, as well as mortality, were all comparable among patients undergoing a liver resection, regardless as to whether the operation was performed open or via an MIS approach (all p?>?0.05). Mean total payments for open pancreatic surgery were on average $1421 higher in the open versus MIS pancreatic group (p?=?0.01); in contrast, there was no difference in the overall payment for hepatic resection (p?>?0.05).

Conclusion

The MIS approach was underutilized among patients undergoing liver and pancreatic procedures. MIS was associated with lower complication and readmission and shorter LOS, as well as comparable/slightly lower Medicare payments, compared with the open approach. The MIS approach should strongly be considered among older patients undergoing liver and pancreatic procedures.

     

Preoperative hyponatremia is associated with postoperative major morbidity,prolonged length of stay,non-home discharge,and readmission in total shoulder arthroplasty

IntroductionHyponatremia is a known risk factor for postoperative complications, but prior research has not investigated its outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study was to determine the association between preoperative hyponatremia and postoperative 30-day major morbidity, 30-day reoperation, length of stay (LOS), non-home discharge, and 30-day readmission.MethodsPatients undergoing anatomic or reverse TSA from 2012 to 2016 were identified in the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database. A multiple logistic regression model was estimated for associated outcomes. An alpha level of 0.005 was used after accounting for Bonferroni correction.ResultsPrimary analysis of 12,437 patients showed significant independent association of preoperative hyponatremia with 30-day major morbidity (OR = 2.00; 99% CI: 1.46–2.73), LOS greater than the 75th percentile (OR = 1.63; 99% CI: 1.31–2.03), non-home discharge (OR = 1.73; 99% CI: 1.08–2.79), and 30-day readmission (OR = 1.69; 99% CI: 1.08–2.64), but not with 30-day reoperation (OR = 1.55; 99% CI: 0.75–3.19).ConclusionPreoperative hyponatremia in TSA was significantly associated with increased odds of 30-day postoperative major morbidity, prolonged LOS, non-home discharge, and 30-day readmission compared to preoperative normonatremia. These findings emphasize the importance of pre-admission testing prior to undergoing elective orthopedic procedures. Additional research is needed to stratify hyponatremia by severity and measure the impact of correcting hyponatremia in patients planning on undergoing TSA.Level of EvidenceLevel III; Retrospective Study-Defined     

Is Pseudomonas infection associated with worse outcomes in pediatric perforated appendicitis?

BackgroundThere is little information on the effects of Pseudomonas infection on outcomes in perforated appendicitis. As Pseudomonas is not covered by many empiric appendicitis antibiotic regiments, we hypothesized that children with Pseudomonas would have worse outcomes.MethodsPatients <18 years old undergoing appendectomy for perforated appendicitis at a tertiary children's hospital 2015–2019 were included and were stratified by presence of Pseudomonas on intraoperative culture. The primary outcome was post-operative organ-space infection (SSI).ResultsIntraoperative cultures were collected in 58.4% of patients (n = 149/255) with 22.2% (n = 33) positive for Pseudomonas. SSIs occurred in 21.2% of children with Pseudomonas compared to 20.7% of children without Pseudomonas (p = 0.9). Children with Pseudomonas had longer antibiotic duration (9.1 vs. 6.7 days, p = 0.03) and LOS (6.7 vs. 5.9 days, p = 0.03) than those without, but a similar rate of post-operative interventions (12.2% vs. 19.0%, p = 0.4), hospital costs ($28,860 vs. $23,945, p = 0.3), ED visits (9.1% vs. 19.9%, p = 0.3), and readmissions (9.1% vs. 9.5%, p = 1).ConclusionPseudomonas was identified in 22% children with perforated appendicitis and was associated with longer antibiotic durations and LOS, but similar rates of SSI, post-operative interventions, and readmissions compared to children without Pseudomonas. Empiric coverage of Pseudomonas may not be necessary.     

Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BackgroundThere is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA.MethodsWe searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders.ResultsThe risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I² = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I² = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001).ConclusionMental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.     

Incidence,risk factors and clinical implications of postoperative urinary tract infection in geriatric hip fractures

IntroductionPostoperative urinary tract infection (UTI) is common in geriatric patients; however, little is known about the impact of UTI in orthopedic trauma. The present study was designed to determine the risk factors and clinical impact of postoperative urinary tract infection (UTI) in acute geriatric hip fractures.Patients and methodsGeriatric patients (≥65 years of age) undergoing hip fracture surgery were identified within the American College of Surgeons National Surgical Quality Improvement Program between 2016 and 2019. Patients presenting with UTI at the time of surgery were excluded. Baseline characteristics and outcomes were compared between patients with and without postoperative UTI. Multivariate logistic regression was performed, controlling for potential confounders.ResultsA total of 46,263 patients included in the study. Overall, 1,397 (3.02%) patients had postoperative UTI. Patients who developed postoperative UTI had higher rates of pneumonia (6.44% vs. 3.76%, p < 0.001), DVT (2.22% vs. 1.04%, p < 0.001), sepsis (7.73% vs. 0.62%, p < 0.001), and more frequently experienced postoperative hospital lengths of stay exceeding 6 days (37.94% vs. 20.33%, p < 0.001). Hospital readmission occurred more frequently in patients with postoperative UTI (24.55% vs. 7.85%, p < 0.001), but surprisingly, these patients had a lower mortality rate (1.36% vs. 2.2%, p < 0.001). Adjusted analysis demonstrated the following variables associated with postoperative UTI: age ≥ 85 (OR = 1.37, 95%CI = 1.08 - 1.73), ASA class ≥ 3 (OR = 1.59, 95%CI = 1.21 – 2.08,), chronic steroid use (OR = 1.451, 95%CI = 1.05 - 1.89), blood transfusion (OR = 1.24, 95%CI = 1.05 - 1.48), and >2 days delay from admission to operation (OR = 1.37, 95%CI = 1.05 - 1.79). Postoperative UTI was significantly associated with sepsis (OR = 7.65, 95%CI = 5.72 – 10.21), postoperative length of stay >2 days (OR = 1.83, 95%CI = 1.07 – 3.13), and readmission (OR = 3, 95%CI = 2.54 – 3.55).ConclusionsIn our study, postoperative UTI was found in 3% of geriatric hip fracture patients. Predictors of postoperative UTI were age ≥ 85, ASA class ≥ 3, chronic steroid use, blood transfusion, and time to operation > 2 days from admission. Results showed that postoperative UTI is independently associated with sepsis, postoperative length of stay beyond 2 days, and hospital readmission. To diminish the risk of UTI and its consequences, we recommend operating geriatric hip fractures in 24–48 hours after admission.     

The direct anterior approach is safe and shortens hospital length of stay following hemiarthroplasty for neck of femur fracture

ObjectiveTo investigate the safety of using the anterior approach (AA), compared to the lateral approach (LA), in hemiarthroplasty for the treatment of displaced neck of femur fractures.DesignRetrospective case-control match cohort study.SettingLevel 1 trauma center.PatientsRetrospective review of prospectively collected data for 39 consecutive intracapsular hip fractures treated with hemiarthroplasty using an AA between 2017 and 2021. Patients operated with the AA were matched in 1:2 ratio with patients that had hemiarthroplasty via a LA.Main Outcome MeasuresDischarge destination, 90-day emergency room (ER) visit or readmission rate, inpatient and 90-day mortality rate, inpatient medical complications, 90-day mechanical complications, 90-day reoperation, and length of hospital stay (LOS).ResultsDischarge destination (p = 0.695), 90-day ER visit or readmission rate (p = 0.315), inpatient (p = 0.719) and 90-day mortality rate (p = 0.815), medical complications (p = 0.524), mechanical complications (p = 0.150) were similar between cohorts. Five patients, all in the LA-group, required re-operations within 90-days (p = 0.106). Patients in AA-group had shorter LOS (9.3 days, 95% CI [7.6–11.1] vs. 14.7 days [95% CI 12.2–17.3], p = 0.002).ConclusionsThe AA can be safely introduced for the treatment of hip fractures. Similar short-term outcomes relative to the LA were identified. The shorter LOS may reflect the improved early functional recovery offered from the muscle-sparing AA technique. Future, level-1 data should include early- and longer term functional outcome along with cost-effectiveness.     

Comparison of laparoscopic percutaneous extraperitoneal closure and laparoscopic intracorporeal suture in pediatric hernia repair

BackgroundLaparoscopic inguinal repair use is rapidly growing because it is a minimally invasive surgery (MIS) technique. However, there is insufficient evidence to support the use of one MIS over others. We compared laparoscopic intracorporeal suture (LIS) and laparoscopic percutaneous extraperitoneal closure (LPEC) to determine which technique is superior.MethodsBetween February 2017 and December 2019, 260 children who underwent LPEC and 214 children who underwent LIS were enrolled. Operative time, recovery score, and patient cosmetic satisfaction were compared. A total of 108 propensity score-matched pairs were analyzed using paired t-test for continuous measurements and McNemar test for categorical variables.ResultsThe mean surgery time was lower in the LPEC group for both unilateral (15.76 ± 5.35 vs. 19 ± 5.71 min; p = 0.04) and bilateral (21.56 ± 5.7 vs. 26.38 ± 6.94 min; p = 0.01) surgeries. The LPEC group required shorter time for complete recovery (p = 0.017). The mean rating for scar visibility was higher in the LIS group (p = 0.02); however, both groups had high levels of cosmetic satisfaction (p = 0.125).ConclusionLPEC for hernia repair is safe and efficient in children and reduced operative time, hastened recovery, and provided excellent cosmetic results.     

Hospital Frailty Risk Score Predicts Adverse Events in Primary Total Hip and Knee Arthroplasty

BackgroundThe Hospital Frailty Risk Score (HFRS) is a validated geriatric comorbidity measure derived from routinely collected administrative data. The purpose of this study is to evaluate the utility of the HFRS as a predictor for postoperative adverse events after primary total hip (THA) and knee (TKA) arthroplasty.MethodsIn a retrospective analysis of 8250 patients who had undergone THA or TKA between 2011 and 2019, the HFRS was calculated for each patient. Reoperation rates, readmission rates, complication rates, and transfusion rates were compared between patients with low and intermediate or high frailty risk. Multivariate logistic regression models were used to assess the relationship between the HFRS and postoperative adverse events.ResultsPatients with intermediate or high frailty risk showed a higher rate of reoperation (10.6% vs 4.1%, P < .001), readmission (9.6% vs 4.3%, P < .001), surgical complications (9.1% vs 1.8%, P < .001), internal complications (7.3% vs 1.1%, P < .001), other complications (24.4% vs 2.0%, P < .001), Clavien-Dindo grade IV complications (4.1% vs 1.5%, P < .001), and transfusion (10.4% vs 1.3%, P < .001). Multivariate logistic regression analyses revealed a high HFRS as independent risk factor for reoperation (odds ratio [OR] = 2.1; 95% confidence interval [CI], 1.46-3.09; P < .001), readmission (OR = 1.78; 95% CI, 1.21-2.61; P = .003), internal complications (OR = 3.72; 95% CI, 2.28-6.08; P < .001), surgical complications (OR = 3.74; 95% CI, 2.41-5.82; P < .001), and other complications (OR = 9.00; 95% CI, 6.58-12.32; P < .001).ConclusionThe HFRS predicts adverse events after THA and TKA. As it derives from routinely collected data, the HFRS enables hospitals to identify at-risk patients without extra effort or expense.Level of EvidenceLevel III–retrospective cohort study.     

Effects of chronic kidney disease on perioperative and 180-day complication rates after total shoulder arthroplasty

BackgroundChronic kidney disease (CKD) is associated with increased risk of complications in total hip arthroplasty and total knee arthroplasty. Despite this known association, there are little data regarding the effect of outcomes in patients undergoing total shoulder arthroplasty (TSA). The purpose of this study is to identify the effects of CKD on patient outcomes after TSA.MethodsThe National Readmissions Database was queried from 2010 to 2017 to identify all primary TSA patients (n = 62,455). CKD was identified using International Classification of Diseases, Ninth Revision and International Classification of Diseases, Tenth Revision codes. Chi-squared analysis and multivariate regression were used to analyze differences in outcomes and the impact of CKD stage.ResultsCKD patients had higher rates of 180-day readmissions, 180-day mortality, acute renal failure (ARF), transfusions, urinary tract infections (UTI), acute respiratory distress syndrome (ARDS), pneumonia, and gastrointestinal (GI) complications. Stage 3 CKD (odds ratio [OR] = 1.378; P = .002), stage 4 CKD (OR = 1.805; P = .027), and unspecified CKD stage (OR = 1.787; P < .001) were at increased odds of 180-day readmission. Stage 4 CKD (OR = 10.647; P = .034) was associated with increased odds of 180-day mortality. Stage 2 CKD had increased odds of GI complications (OR = 8.365; P = .004). Both stage 3 CKD (OR = 1.463; P = .038) and stage 4 CKD (OR = 2.465; P = .033) had increased odds of UTI. Stage 5 CKD (OR = 36.143; P < .001) had increased odds of ARDS. Stage 2 CKD had increased odds of thrombosis (OR = 7.869; P = .007). Stage 2 (OR = 4.826; P < .001), stage 3 (OR = 5.724; P < .001), stage 4 (OR = 11.162; P < .001), stage 5 (OR = 31.328; P < .001), and unspecified CKD stage (OR = 4.801; P < .001) were associated with increased odds of ARF. Stage 2 CKD (OR = 12.809; P = .014), stage 3 (OR = 7.351; P = .001), and stage 4 (OR = 39.684; P < .001) were associated with increased odds of transfusions.ConclusionCKD is associated with increased risk of complications, including postoperative ARF, transfusions, UTI, ARDS, pneumonia, and GI complications. Patients with CKD also have increased 180-day readmission rates and 180-day mortality rates. Increasing stage of CKD is associated with increasing odds of 180-day readmission, postoperative ARF, and transfusions. Surgeons should consider these increased risks in the decision-making process during preoperative evaluation. These complications would likely increase cost, which raises the need for further evaluation and stratification of risk in patients who use bundled payment systems.Level of evidenceLevel III; Case-Control Study     

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BackgroundThe purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.MethodsThis was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.ResultsFrom 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.ConclusionIn this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.Level of evidence3 (Retrospective cohort study).     

Enhanced recovery after elective craniotomy: A randomized controlled trial

Study objectivesEnhanced recovery after surgery (ERAS) protocols have been proven to improve outcomes but have not been widely used in neurosurgery. The purpose of this study was to design a multidisciplinary enhanced recovery after elective craniotomy protocol and to evaluate its clinical efficacy and safety after implementation.DesignA prospective randomized controlled trial.SettingThe setting is at an operating room, a post-anesthesia care unit, and a hospital ward.PatientsThis randomized controlled trial (RCT) prospectively analyzed 151 patients who underwent elective craniotomy between January 2019 and June 2020.InterventionsThe neurosurgical ERAS group was cared for with evidence-based systematic optimization approaches, while the control group received routine care.MeasurementsThe primary outcomes were the postoperative length of stay (LOS) and hospitalization costs. The secondary outcomes included 30-day readmission rates, postoperative complications, postoperative pain scores, length of intensive care unit (ICU) stay, duration of the drainage tube, time to oral intake, time to ambulation, and postoperative functional recovery status.Main resultsAfter ERAS protocol implementation, the median postoperative LOS (4 days to 3 days, difference [95% confidence interval, CI], 2 [[1], [2]], P < 0.0001) and hospitalization costs (6266 USD to 5880 USD, difference [95% CI], 427.0 [234.8 to 633.6], P < 0.0001) decreased. Compared to routine perioperative care, the ERAS protocol reduced the incidence of postoperative nausea and vomiting (PONV) (28.0% to 9.2%, adjusted odds ratio [OR] 0.3, 95% CI 0.1–0.7, P = 0.003), shortened urinary catheter removal time by 24 h (64.0% to 83.0%, adjusted OR 2.9, 95% CI 1.3–6.5, P = 0.031), improved ambulation on postoperative day 1 (POD 1) (30.7% to 75.0%, adjusted OR 7.5, 95% CI 3.6–15.8, P < 0.0001), shortened the time to oral intake (15 h to 13 h, difference [95% CI], 3 [[1], [2], [3], [4]], P < 0.001), and improved perioperative pain management.ConclusionsImplementation of an enhanced recovery after elective craniotomy protocol had significant benefits over conventional perioperative management. It was associated with a significant reduction in postoperative length of stay, medical cost, and postoperative complications.