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Most downloaded biology preprints, since beginning of last month

in category surgery

95 results found. For more information, click each entry to expand.

1: Laser speckle contrast imaging for visualizing blood flow during cerebral aneurysm surgery: A comparison with indocyanine green angiography
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Posted 29 Apr 2021

Laser speckle contrast imaging for visualizing blood flow during cerebral aneurysm surgery: A comparison with indocyanine green angiography
589 downloads medRxiv surgery

David R Miller, Ramsey Ashour, Colin T. Sullender, Andrew Dunn

Laser speckle contrast imaging (LSCI) has emerged as a promising tool for intraoperative cerebral blood flow (CBF) monitoring because it produces real-time full-field blood flow maps non-invasively and label-free. In this study, we compare LSCI with indocyanine green angiography (ICGA) to assess CBF during aneurysm clipping surgery in humans. LSCI hardware was attached to the surgical microscope prior to the start of each surgery and did not interfere with the sterile draping of the microscope or normal operation of the microscope. LSCI and ICGA were performed simultaneously to visualize CBF in n=4 aneurysm clipping cases, and LSCI was performed throughout each surgery when the microscope was positioned over the patient. To more easily visualize CBF in real-time, LSCI images were overlaid on the built-in microscope white light camera images and displayed to the neurosurgeon in real-time. Blood flow changes before, during, and after an aneurysm clipping were visualized with LSCI and later verified with ICGA. LSCI was performed continuously throughout the aneurysm clipping process, providing the surgeon with immediate actionable information on the success of the clipping. The results demonstrate that LSCI and ICGA provide different, yet complementary information about vessel perfusion.

2: Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action
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Posted 09 Apr 2021

Racial and Ethnic Inequities in Mortality During Hospitalization for Traumatic Brain Injury: A Call to Action
146 downloads medRxiv surgery

Emma A Richie, Joseph G Nugent, Ahmed M Raslan

The health disparities which drive inequities in health outcomes have long plagued our already worn healthcare system and are often dismissed as being a result of social determinants of health. Herein, we explore the nature of these inequities by comparing outcomes for racial and ethnic minority patients suffering from traumatic brain injury (TBI). We retrospectively reviewed all patients enrolled in the Trauma One Database at the Oregon Health & Science University Hospital from 2006 to October 2017 with an abbreviated injury scale (AIS) scale for the head or neck greater than 2. Racial and ethnic minority patients were defined as non-White or Hispanic. A total of 6,352 patients were included in our analysis with 1,504 in the racial and ethnic minority cohort vs. 4,848 in the non-minority cohort. A propensity score (PS) model was generated to account for differences in baseline characteristics between these cohorts to generate 1,500 matched pairs. The adjusted hazard ratio for in-hospital mortality for minority patients was 2.21 (95% Confidence Interval (CI) 1.43-3.41, p<0.001) using injury type, probability of survival, and operative status as covariates. Treating patients under our care is our greatest privilege and responsibility as physicians. As such, we have a societal duty to recognize and accept that the effects of structural racism have taken hold of our patients health long before they arrive in our trauma bays, ICU beds, and operating tables. These disparities permeate our society and contribute to inequitable health outcomes, and we must take action to identify the factors which perpetuate this disproportionate suffering. Simply treating the minority of patients who require surgical intervention or clinical consultation is not enough. Our roles demand that we recognize these larger social factors acting upstream on our patients before they enter our fractioned healthcare system which often fosters the very mistrust that hides them from our otherwise watchful eyes in the first place. What shape, if any, these health inequities take among other nations will enable us to better understand the root of these problems in our society and allow us to work together toward equitable healthcare for all victims of traumatic injury.

3: Postoperative morbidity after liver resection- A Systemic review, meta-analysis, and metaregression of factors affecting them.
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Posted 09 Apr 2021

Postoperative morbidity after liver resection- A Systemic review, meta-analysis, and metaregression of factors affecting them.
91 downloads medRxiv surgery

BHAVIN VASAVADA, HARDIK PATEL

Aim of the study: This systemic review and meta-analysis aimed to analyze post-operative morbidity after liver resection, and also study various factors associated with mortality via metaregression analysis. Material and Methods: PubMed, Cochrane Library, Embase, google scholar, web of science with keywords like liver resection; mortality; hepatectomy. Weighted percentage post-operative morbidities were analyzed. Meta-analysis and meta-regression were done by the DerSimonian-Liard random effect model. Heterogeneity was assessed using the Higgins I2 test. Publication bias was assessed using a funnel plot. Funnel plot asymmetry was evaluated by Eggers test. Morbidity was defined as any postoperative morbidity mentioned. Results: A total of 46 studies was included in the final analysis. Total 45771 patients underwent liver resections. 16111 patients experienced complications during the postoperative period. Weighted post-operative morbidity was 30.2% ( 95 % C.I. 24.8-35.7%). Heterogeneity was high with I2 99.46% and p-value <0.01. On univariate analysis, major liver resections were significantly associated with heterogeneity. (p=0.024). However, residual heterogeneity was still high with I2 98.62%, p<0.001. So, multifactor metaregression analysis major hepatectomy (p<0.001), Open hepatectomy (p=0.001), cirrhotic liver (p=0.002), age (p<0.001), blood loss (p<0.001), and colorectal metastasis (p<0.001) independently associated with postoperative morbidity. Residual heterogeneity was moderate I2= 39.9% and nonsignificant p=0.189. Conclusion: Liver resection is associated with high postoperative morbidity and various factors like major hepatectomy, Open hepatectomy, cirrhotic liver, blood loss, and colorectal metastasis were associated with morbidity and responsible for heterogeneity across the studies.

4: Management Algorithm of External Fixation in Lower Leg Arterial Injury for Limb Salvages
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Posted 03 Mar 2021

Management Algorithm of External Fixation in Lower Leg Arterial Injury for Limb Salvages
87 downloads medRxiv surgery

Lei Jin, Song Zhang, Motao Liu, Yuxuan Zhang, Xin Lin, Dehong Feng, Kejia Hu

PurposeThe purpose of this study was to review the roles of using external fixation to rescue the patients who sustained arterial injuries in the lower legs. MethodsDemographics, surgical treatment and outcomes in 88 patients with lower leg arterial injuries treated by external fixation at two trauma centers from 2009 to 2018 were reviewed. The primary outcome was the rate of successful lower leg salvage, while secondary outcomes were complications and functional recovery. Results80 patients (90 legs) maintained a successful lower leg salvage. The patients were followed up for an average of 15.5{+/-}5.5 months. 6 patients (8 pins) experienced pin-tract infection, pins loosening happened in 2 patients (4 pins), 7 patients (7 legs) developed wound superficial infection, 3 patients (3 legs) with a deep infection developed osteomyelitis, 16 patients (17 legs) suffered the bone nonunion or bone defect. The average healing time of fracture was 5.6{+/-}4.3months. The maintain of external fixation average time was 5.8{+/-}3.6 months. ConclusionWith correctly judging the condition of limb ischemia, mastering reasonably the operation indications, and preventing complications, good clinical effects can be achieved when external fixation is used. Level of evidenceRetrospective cohort, level IV.

5: Impact of the COVID-19 pandemic on surgical procedures in Brazil: a descriptive study
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Posted 20 Mar 2021

Impact of the COVID-19 pandemic on surgical procedures in Brazil: a descriptive study
86 downloads medRxiv surgery

Barbara Okabaiasse Luizeti, Victor Augusto Santos Perli, Gabriel da Costa, Igor Eckert, Aluisio Marino Roma, Karina Miura da Costa

Background: The COVID-19 pandemic has deeply affected medical practice, and changes in healthcare activities were needed to minimize the overload and avoid healthcare systems collapse. The aim of this study was to evaluate the impact of the pandemic on surgical procedures in Brazil. Materials and Methods: We conducted a descriptive study of the number of hospitalizations for surgical procedures in Brazil from 2016 to 2020. Data were collected from the Brazilian Department of Informatics of the Unified Health System (DATASUS). Analyzes were performed according to the type of procedure, geographical region, subgroups of surgical procedures, and the number of surgeries from 2020 were compared with the average from 2016 to 2019. Results: There were 4,009,116 hospitalizations for surgical procedures in the Brazilian Public Health System in 2020. When comparing it to the average of hospitalizations from 2016-2019, there was a decrease of 14.88% [95%IC (14.82-14.93)]. Decrease rates were 34.82% [95%IC (34.73-34.90)] for elective procedures and 1.11% [95%IC (1.07-1.13)] for urgent procedures. Decrease rates were similar in all the five regions of the country (average 14.17%). Surgical procedure subgroups with the highest decrease rates were endocrine gland surgery (48.03%), breast surgery (40.68%), oral and maxillofacial surgery (37.03%), surgery of the upper airways, face, head and neck (36.06%), and minor surgeries and surgeries of skin, subcutaneous tissue and mucosa (33.16%). Conclusion: The overload of healthcare facilities has demanded a reduction of non-urgent activities to prevent a collapse of healthcare systems, resulting in a decrease in elective surgeries. Recommendations about the performance of surgical procedures were made, and continuous refinements of these recommendations are encouraged.

6: Surgical site infection and its associated factors in Ethiopia: A systematic review and meta-analysis
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Posted 30 Dec 2019

Surgical site infection and its associated factors in Ethiopia: A systematic review and meta-analysis
85 downloads medRxiv surgery

Wondimeneh Shibabaw Shiferaw, Yared Asmare Aynalem, Tadesse Yirga Akalu, Pammla Margaret Petrucka

BackgroundDespite being a preventable complication of surgical procedures, surgical site infections (SSIs) continue to threaten public health with significant impacts on the patients and the health-care human and financial resources. With millions affected globally, there issignificant variation in the primary studies on the prevalence of SSIs in Ethiopia. Therefore, this study aimed to estimate the pooled prevalence of SSI and its associated factors among postoperative patients in Ethiopia. MethodsPubMed, Scopus, Psyinfo, African Journals Online, and Google Scholar were searched for studies that looked at SSI in postoperative patients. A funnel plot and Eggers regression test were used to determine publication bias. The I2 statistic was used to check heterogeneity between the studies. DerSimonian and Laird random-effects model was applied to estimate the pooled effect size, odds ratios (ORs), and 95% confidence interval (CIs) across studies. The subgroup analysis was conducted by region, sample size, and year of publication. Sensitivity analysis was deployed to determine the effect of a single study on the overall estimation. Analysis was done using STATA Version 14 software. ResultA total of 24 studies with 13,136 study participants were included in this study. The estimated pooled prevalence of SSI in Ethiopia was 12.3% (95% CI: 10.19, 14.42). Duration of surgery > 1 hour (AOR = 1.78; 95% CI: 1.08 -2.94), diabetes mellitus (AOR = 3.25; 95% CI: 1.51-6.99), American Society of Anaesthesiologists score >1 (AOR = 2.51; 95% CI: 1.07-5.91), previous surgery (AOR = 2.5; 95% CI: 1.77-3.53), clean-contaminated wound (AOR = 2.15; 95% CI: 1.52-3.04), and preoperative hospital stay > 7 day (AOR = 5.76; 95% CI: 1.15-28.86), were significantly associated with SSI. ConclusionThe prevalence of SSI among postoperative patients in Ethiopia remains high with a pooled prevalence of 12.3% in 24 extracted studies. Therefore, situation based interventions and region context-specific preventive strategies should be developed to reduce the prevalence of SSI among postoperative patients.

7: Recent trends in postoperative mortality after liver resection- A systemic review and metanalysis of studies published in last 5 years and metaregression of various factors affecting 90 days mortality.
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Posted 29 Mar 2021

Recent trends in postoperative mortality after liver resection- A systemic review and metanalysis of studies published in last 5 years and metaregression of various factors affecting 90 days mortality.
82 downloads medRxiv surgery

BHAVIN VASAVADA, hardik patel

Aim: The aim of this systemic review and meta-analysis was to analyse 90 days mortality after liver resection, and also study various factors associated with mortality via univariate and multivariate metaregression. Methods: PubMed, Cochrane library, Embase, google scholar, web of science with keywords like liver resection, mortalit, hepatectomy. Weighted percentage 90 days mortalities were analysed. univariate metaregression was done by DerSimonian-Liard methods. Major hepatectomy, open surgery, cirrhotic livers, blood loss, hepatectomy for hepatocellular carcinoma, hepatectomy for colorectal liver metastasis were taken as moderators in metaregression analysis. We decided to enter all co-variants in multivariate model to look for mixed effects. Heterogeneity was assessed using the Higgins I2 test, with values of 25%, 50% and 75% indicating low, moderate and high degrees of heterogeneity. Cohort studies were assessed for bias using the Newcastle-Ottawa Scale to assess for the risk of bias. Publication bias was assessed using funnel plot. Funnel plot asymmetry was evaluated by Egger test. Results: Total 29931 patients data who underwent liver resections for various etiologies were pooled from 41 studied included1257 patients died within 90 days post operatively. Weighted 90 days mortality was 3.6% (95% C.I 2.8% -4.4%). However, heterogeneity of the analysis was high with I2 94.625%.(p<0.001). We analysed various covariates like major hepatectomy, Age of the patient, blood loss, open surgery, liver resections done for hepatocellular carcinoma or colorectal liver metastasis and cirrhotic liver to check for their association with heterogeneity in the analysis and hence 90 days mortality. On univariate metaregression analysis major hepatectomy (p<0.001), Open hepatectomy (p<0.001), blood loss (p=0.002) was associated with heterogeneity in the analysis and 90 days mortality. On multivariate metaregression Major hepatectomy(p=0.003) and Open surgery (p=0.012) was independently associated with higher 90 days mortality, and liver resection for colorectal liver metastasis was independently associated with lesser 90 days mortality (z= -4.11,p<0.01). Residual heterogeneity after all factor multivariate metaregression model was none (I2=0,Tau2=0, H2=1) and nonsignificant (p=0.49). Conclusion: Major hepatectomy, open hepatectomy, and cirrhotic background is associated with higher mortality rates and colorectal liver metastasis is associated with lower peri operative mortality rates.

8: Research priorities for lower limb amputation in patients with vascular disease
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Posted 24 May 2021

Research priorities for lower limb amputation in patients with vascular disease
81 downloads medRxiv surgery

David Bosanquet, Sandip Nandhra, Kitty Wong, Judith Long, Ian Chetter, Robert Hinchliffe, The VSGBI Amputation Special Interest Group James-Lind Alliance Priority Setting Partnership Group

Introduction Lower limb amputation is a life-changing event for patients and can be associated with high mortality and morbidity rates. Research into this critical part of vascular surgery is limited. The Vascular Society of Great Britain and Ireland (VSGBI) in partnership with the James Lind Alliance (JLA) process, aimed to identify and develop key research priorities for amputation. Methods A modified JLA Priority Setting Partnership was undertaken, encompassing all vascular practice. Two separate Delphi processes to identify research topics were undertaken with healthcare professionals, patients and carers, led by the VSGBI. The priorities were then ranked by the same participants and amalgamated to produce a list for final prioritisation. The final consensus meeting was attended by patients, carers and healthcare professionals from a variety of backgrounds involved in the care of people with amputation. Using a nominal group technique, the top ten research priorities were identified. Results A total of 481 clinicians submitted 1231 research questions relating to vascular surgery in general. 63 amputation-specific research questions were combined into 5 final clinical questions. 373 patients or carers submitted 582 research questions related to vascular surgery in general. Nine amputation-specific research questions were identified after combining similar questions. Amalgamating both the clinician and patient questions, 12 questions were discussed at the final prioritisation meeting and the top 10 identified. These related to amputation prevention, supporting rehabilitation, improving clinical outcomes following amputation (preventing/treating pain including phantom limb pain and improving wound healing) and research into information provision for patients undergoing amputation. Conclusion The top 10 research priority areas in vascular amputation provide guidance for researchers, clinicians, and funders on the direction of future research questions that are important to both healthcare professionals and patients.

9: Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study
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Posted 20 Feb 2021

Mortality after surgery with SARS-CoV-2 infection in England: A population-wide epidemiological study
81 downloads medRxiv surgery

T E Abbott, A J Fowler, T. D. Dobbs, J Gibson, T. Shahid, P. Dias, A. Akbari, I S Whitaker, R M Pearse

ObjectivesTo confirm the incidence of perioperative SARS-CoV-2 infection and associated mortality after surgery. Design and settingAnalysis of routine electronic health record data from National Health Service (NHS) hospitals in England. MethodsWe extracted data from Hospital Episode Statistics in England describing adult patients undergoing surgery between 1st January 2020 and 31st October 2020. The exposure was SARS-CoV-2 infection defined by ICD-10 codes. The primary outcome measure was 90-day in-hospital mortality. Data were analysed using multivariable logistic regression adjusted for age, sex, Charlson co-morbidity index, index of multiple deprivation, presence of cancer, surgical procedure type and admission acuity. Results are presented as n (%) and odds ratios (OR) with 95% confidence intervals. ResultsWe identified 1,972,153 patients undergoing surgery of whom 11,940 (0.6%) had SARS-CoV-2. In total, 19,100 (1.0%) patients died in hospital. SARS-CoV-2 infection was associated with a much greater risk of death (SARS-CoV-2: 2,618/11,940 [21.9%] vs No SARS-CoV-2: 16,482/1,960,213 [0.8%]; OR: 5.8 [5.5 - 6.1]; p<0.001). Amongst patients undergoing elective surgery 1,030/1,374,985 (0.1%) had SARS-CoV-2 of whom 83/1,030 (8.1%) died, compared with 1,092/1,373,955 (0.1%) patients without SARS-CoV-2 (OR: 29.0 [22.5 -37.3]; p<0.001). Amongst patients undergoing emergency surgery 9,742/437,891 (2.2%) patients had SARS-CoV-2, of whom 2,466/9,742 (25.3%) died compared with 14,817/428,149 (3.5%) patients without SARS-CoV-2 (OR: 5.7 [5.4 - 6.0]; p<0.001). ConclusionsThe low incidence of SARS-CoV-2 infection in NHS surgical pathways suggests current infection prevention and control policies are highly effective. However, the high mortality amongst patients with SARS-CoV-2 suggests these precautions cannot be safely relaxed. Summary boxesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIHigh mortality rates have been reported amongst surgical patients who develop COVID-19 but we dont know how this compares to the concurrent surgical population unaffected by COVID-19. C_LIO_LIStrict infection prevention and control procedures have substantially reduced the capacity of surgical treatment pathways in many hospitals. C_LIO_LIThe very large backlog in delayed and cancelled surgical procedures is a growing public health concern. C_LI What this study addsO_LIFewer than 1 in 100 surgical patients are affected by COVID-19 in the English National Health Service. C_LIO_LIElective surgical patients who do develop COVID-19 are 30 times more likely to die while in hospital. C_LIO_LIInfection prevention and control procedures in NHS surgical pathways are highly effective but cannot be safely relaxed. C_LI

10: Impact of Asian and black donor and recipient ethnicity on the outcomes after deceased donor kidney transplantation in the United Kingdom
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Posted 07 May 2021

Impact of Asian and black donor and recipient ethnicity on the outcomes after deceased donor kidney transplantation in the United Kingdom
80 downloads medRxiv surgery

Abdul Rahman Hakeem, Sonal Asthana, Rachel Johnson, Chloe Brown, Niaz Ahmad

Background: Patients of Asian and black ethnicity face disadvantage on the renal transplant waiting list in the United Kingdom, because of lack of HLA and blood group matched donors from an overwhelmingly white deceased donor pool. This study evaluates outcomes of renal allografts arising from Asian and black donors. Methods: The UK Transplant Registry was analysed for adult deceased donor kidney only transplants performed during January 2001 to December 2015. Results: Asian and black ethnicity patients constituted 12.4% and 6.7% of all deceased donor recipients but only 1.6% and 1.2% of all deceased donors, respectively. Across all recipients, and unsurprisingly given the predominantly white recipient pool, HLA matching was superior for grafts from white donors than from Asian and black donors (p less than 0.0001). Unadjusted survival analysis demonstrated significantly inferior long-term allograft outcomes associated with Asian and black donors, compared to white donors (7 year graft survival 71.9%, 74.0% and 80.5%; log rank p 0.0007, respectively). On Cox regression analysis, Asian donor (HR 1.37 for Asian donors vs. white donors as baseline) and black recipient (HR 1.21 for black recipients vs. white recipient as baseline) ethnicities were associated with poorer outcomes than white counterparts, and on ethnicity matching, compared with the white donor to white recipient baseline group and adjusting for other donor and recipient factors, 5 year graft outcomes were significantly poorer for black donor to black (HR 1.92 (1.11 to 3.32), p 0.02), Asian donor to white recipient (HR 1.56 (1.09 to 2.24), p 0.016) and white donor-black recipient (HR 1.22 (1.05 to 1.42), p 0.011) combinations in decreasing order of worse unadjusted 5 year graft survival. Conclusions: Increased deceased donation among ethnic minority communities would benefit the entire recipient pool by increasing the numbers of available organs and may specifically benefit the Asian and black recipients by increasing the numbers of blood group and HLA compatible grafts for allocation but may not improve allograft outcomes.

11: Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians
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Posted 29 Jan 2021

Timing and Dose of Pharmacological Thromboprophylaxis in Adult Trauma Patients: Perceptions, Barriers, and Experience of Saudi Arabia Practicing Physicians
79 downloads medRxiv surgery

Marwa R Amer, Mohammed Bawazeer, Khalid Maghrabi, Rashid Amin, Edward De Vol, Mohammed Hijazi

Background: Pharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until post injury bleeding risk is perceived to be sufficiently low; yet data for optimal initiation time is lacking. This study assessed practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and non-operative (NOR) solid organ injuries. Methods: Multicenter, cross sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators vs. late initiators and logistic regression models were used to identify factors associated with early initiation of PVTE-Px. Results: Of 102 physicians (29 % response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor , 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography [CT], respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regards to NOR solid organ injuries [gunshot wound to the liver and grade IV splenic injuries], 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen. Conclusions: Variations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians judgment is recommended.

12: Environmental impact and life cycle financial cost of hybrid (reusable/ single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy
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Posted 12 Mar 2021

Environmental impact and life cycle financial cost of hybrid (reusable/ single-use) instruments versus single-use equivalents in laparoscopic cholecystectomy
78 downloads medRxiv surgery

Chantelle Rizan, Mahmood F Bhutta

Background Hybrid surgical instruments contain both single-use and reusable components, potentially bringing together advantages from both approaches. Methods We used Life Cycle Assessment to evaluate environmental impact of hybrid laparoscopic clip appliers, scissors and ports used for a laparoscopic cholecystectomy, comparing these with single-use equivalents. We modelled this using SimaPro to determine 18 midpoint environmental impacts including the carbon footprint, and three aggregated endpoint impacts. We also conducted life cycle cost analysis, taking into account unit cost, decontamination, and disposal costs. Findings The environmental impact of using hybrid instruments for a laparoscopic cholecystectomy was lower than single-use equivalents across 17 midpoint environmental impacts, with mean average reductions of 60%, and costing less than half that of single-use equivalents (GBP 131 versus 282). The carbon footprint of using hybrid versions of all three instruments was around one-quarter of single-use equivalents (1,756 g versus 7,194 g CO2e per operation), and saved an estimated 1.13 e-5 DALYs (disability associated life years, 74% reduction), 2.37 e-8 species.year (loss of local species per year, 76% reduction), and US $ 0.6 in impact on resource depletion (78% reduction). Scenario modelling indicated environmental performance of hybrid instruments was better even given low number of reuses of instruments, decontamination with separate packaging of certain instruments, decontamination using fossil-fuel rich energy sources, or changing carbon intensity of instrument transportation. Interpretation Adoption of hybrid laparoscopic instruments could play an important role in meeting carbon reduction targets for surgery, whilst saving money. Funding This work was funded by Surgical Innovations Ltd who manufacture hybrid laparoscopic instruments.

13: A comparative analysis of the health, financial, equity, and cost-effectiveness impacts of maxillofacial surgery in Guinea
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Posted 26 Mar 2021

A comparative analysis of the health, financial, equity, and cost-effectiveness impacts of maxillofacial surgery in Guinea
72 downloads medRxiv surgery

Mirjam Hamer, Dennis Alcorn, Ibrahima Diallo, Fatoumata B Y Bah, Alhassane Conde, Lancine Traore, Etienne Faya Millimouno, Chelsea Peacock, Chris Glasgo, Peter E Linz, Mark G Shrime, Omar Raphiou Diallo

Background: Non-governmental organizations (NGOs) play a substantive role in the delivery of surgical services in in low- and middle-income countries (LMICs). Assessment of their outcomes, especially as they relate to outcomes of surgery done in country, remains limited. Methods: A prospective analysis of maxillofacial surgery in Guinea. Outcomes of interest were changes in patient health, subjective well-being, and financial status; hardship financing and catastrophic expenditure; equitable distribution of surgical access; and cost-effectiveness. Results: We followed 569 patients requiring maxillofacial surgery in Conakry, Guinea, 114 of whom got care at local university hospitals, and 455 of whom got their care with Mercy Ships, a surgical NGO. Patients were followed for between three months (local) and one year (NGO). All patients reported significant improvement in objective and subjective measures of health and in financial status. Approximately half had to borrow and sell to get care, with NGO patients borrowing less, on average. However, NGO patients faced more risk of catastrophic expenditure (41.2% vs. 28.1%, p < 0.001). NGO patients were significantly poorer, whether financial status was measured by asset wealth (p = 0.014) or monthly income (p < 0.001). Finally, surgical care by the NGO was cost effective. Conclusions: In a prospective analysis of surgical patients in an LMIC, we find that surgery improves health and financial well-being. NGOs may be able to reach patients who would not be able to get care through their local system; however, this comes at a cost of increased initial financial risk. Finally, NGO-based surgical care is cost-effective.

14: Unplanned Hospital Visits after Ambulatory Surgical Care
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Posted 12 Mar 2021

Unplanned Hospital Visits after Ambulatory Surgical Care
72 downloads medRxiv surgery

Tasce Bongiovanni, Craig Parzynski, Isuru Ranasinghe, Michael A. Steinman, Joseph S Ross

Objectives: We sought to assess the rate of unplanned hospital visits among patients undergoing ambulatory surgery. Summary Background Data: The majority of surgeries performed in the United States now take place in outpatient settings. Post-discharge hospital visit rates have been shown to vary widely, suggesting variation in surgical or discharge care quality. Complicating efforts to address quality, most facilities and surgeons are unaware of their patients' hospital visits after surgery since patients may present to a different hospital. Methods: We used state-level, administrative data from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project from California to assess unplanned hospital visits after ambulatory surgery. To compare rates across centers, we determined the age, sex, and procedure-adjusted rates of hospital visits for each facility using 2-level, hierarchical, generalized linear models using methods similar to existing Centers for Medicare and Medicaid Services measures. Results: Among a total of 1,260,619 ambulatory same-day surgeries from 440 surgical facilities, the risk adjusted 30-day rate of unplanned hospital visits was 4.8%, with emergency department visits of 3.1% and hospital admissions of 1.7%. Several patient characteristics were associated with increased risk of unplanned hospitals visits, including increased age, increased number of comorbidities (using the Elixhauser score), and type of procedure (p<0.001). Conclusions: The overall rate unplanned hospital visits within 30 days after same-day surgery is low but variable, suggesting a difference in the quality of care provided. Further, these rates are higher among specific patient populations and procedure types, suggesting areas for targeted improvement.

15: Surgery & COVID-19: A rapid scoping review of the impact of COVID-19 on surgical services during public health emergencies
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Posted 04 Dec 2020

Surgery & COVID-19: A rapid scoping review of the impact of COVID-19 on surgical services during public health emergencies
71 downloads medRxiv surgery

Connor O'Rielly, Joshua Ng Kamstra, Ania Kania-Richmond, Joseph C Dort, Jonathan White, Jill Robert, Mary Brindle, Khara M Sauro

Background: Healthcare systems globally have been challenged by the COVID-19 pandemic, necessitating the reorganization of surgical services to free capacity within healthcare systems. Objectives: To understand how surgical services have been reorganized during and following public health emergencies, and the consequences of these changes for patients, healthcare providers and healthcare systems. Methods: This rapid scoping review searched academic databases and grey literature sources to identify studies examining surgical service delivery during public health emergencies including COVID-19, and the impact on patients, providers and healthcare systems. Recommendations and guidelines were excluded. Screening was completed in partial (title, abstract) or complete (full text) duplicate following pilot reviews of 50 articles to ensure reliable application of eligibility criteria. Results: One hundred and thirty-two studies were included in this review; 111 described reorganization of surgical services, 55 described the consequences of reorganizing surgical services and six reported actions taken to rebuild surgical capacity in public health emergencies. Reorganizations of surgical services were grouped under six domains: case selection/triage, PPE regulations and practice, workforce composition and deployment, outpatient and inpatient patient care, resident and fellow education, and the hospital or clinical environment. Service reorganizations led to large reductions in non-urgent surgical volumes, increases in surgical wait times, and impacted medical training (i.e., reduced case involvement) and patient outcomes (e.g., increases in pain). Strategies for rebuilding surgical capacity were scarce, but focused on the availability of staff, PPE, and patient readiness for surgery as key factors to consider before resuming services. Conclusions: Reorganization of surgical services in response to public health emergencies appears to be context-dependent and has far-reaching consequences that must be better understood in order to optimize future health system responses to public health emergencies.

16: Portuguese Inguinal Hernia Cohort (PINE) study
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Posted 22 Dec 2020

Portuguese Inguinal Hernia Cohort (PINE) study
71 downloads medRxiv surgery

PT Surg – Portuguese Surgical Research Collaborative, J Simões, AA João, JM Azevedo, M Peyroteo, M Cunha, B Vieira, N Gonçalves, J Costa, AS Soares, JS Pimenta, M Romano, AM Cinza, I Miguel, AR Martins, G Fialho, M Reia, FC Borges, CF Monteiro, AC Soares, P Sousa, S Frade, L Matos, JM Carvas, SF Martins, X Sousa, C. Rodrigues, JR Carvalho, IC Gil, L Castro, N Rombo, AC Quintela, HM Ribeiro, R Parreira, P Santos, F Caires, A Torre, S.C. Rodrigues, AH Guimarães, MF Carvalho, MA Pimentel, DC Santos, CF Ramos, C Cunha, C. Azevedo

PurposeRecent comprehensive guidelines have been published on the management of inguinal hernia. Contrary to other European countries, no Portuguese hernia registry exists. This represents an opportunity to assess outcomes of hernia surgery in the Portuguese population. The primary aim is to define the prevalence of chronic pain after elective inguinal hernia repair. The secondary aims are to identify risk factors for chronic pain after elective inguinal hernia repair, to characterise the management of elective inguinal hernia in public Portuguese hospitals. MethodsProspective national cohort study of patients submitted to elective inguinal hernia repair. The primary outcome is the prevalence of chronic postoperative inguinal pain, according to the EuraHS QoL questionnaire at 3 months postoperatively. The study will be delivered in all Portuguese regions through a collaborative research network. Four 2-week inclusion periods will be open for recruitment. A site-specific questionnaire will capture procedure volume and logistical facilities for hernia surgery. ConclusionThis protocol describes the methodology of a prospective cohort study on the elective management of inguinal hernia. It discusses key challenges and describes how the results will impact future investigation. The study will be conducted across a nationwide collaborative research network, with prospective quality assurance and data validation strategies. It will provide the basis for a more accurate prediction of chronic postoperative inguinal pain and the research on adequate patient selection strategies for surgery and therapeutic strategies for postoperative pain.

17: Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study
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Posted 01 Mar 2021

Surgical activity in England and Wales during the COVID-19 pandemic: a nationwide observational cohort study
70 downloads medRxiv surgery

T. D. Dobbs, J A G Gibson, A J Fowler, T E Abbott, T. Shahid, F Torabi, R Griffiths, R A Lyons, R M Pearse, I S Whitaker

ObjectivesTo report the volume of surgical activity and the number of cancelled surgical procedures during the COVID-19 pandemic. Design and settingAnalysis of electronic health record data from the National Health Service (NHS) in England and Wales. MethodsWe used hospital episode statistics for all adult patients undergoing surgery between 1st January 2020 and 31st December 2020. We identified surgical procedures using a previously published list of procedure codes. Procedures were stratified by urgency of surgery as defined by NHS England. We calculated the deficit of surgical activity by comparing the expected number of procedures from the years 2016-2019 with the actual number of procedures in 2020. We estimated the cumulative number of cancelled procedures by 31st December 2021 according patterns of activity in 2020. ResultsThe total number of surgical procedures carried out in England and Wales in 2020 was 3,102,674 compared to the predicted number of 4,671,338. This represents a 33.6% reduction in the national volume of surgical activity. There were 763,730 emergency surgical procedures (13.4% reduction), compared to 2,338,944 elective surgical procedures (38.6% reduction). The cumulative number of cancelled or postponed procedures was 1,568,664. We estimate that this will increase to 2,358,420 by 31st December 2021. ConclusionsThe volume of surgical activity in England and Wales was reduced by 33.6% in 2020, resulting in over 1,568,664 cancelled operations. This deficit will continue to grow in 2021. Summary boxesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LIThe COVID-19 pandemic necessitated a rapid change in the provision of care, including the suspension of a large proportion of surgical activity C_LIO_LISurgical activity has yet to return to normal and has been further impacted by subsequent waves of the pandemic C_LIO_LIThis will lead to a large backlog of cases C_LI What this study addsO_LI3,102,674 surgical procedures were performed in England and Wales during 2020, a 33.6% reduction on the expected yearly surgical activity C_LIO_LIOver 1.5 million procedures were not performed, with this deficit likely to continue to grow to 2.3 million by the end of 2021 C_LIO_LIThis deficit is the equivalent of more than 6 months of pre-pandemic surgical activity, requiring a monumental financial and logistic challenge to manage C_LI

18: Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials
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Posted 25 Jan 2021

Impact of gastric resection and enteric anastomotic configuration on delayed gastric emptying after pancreaticoduodenectomy: a network meta-analysis of randomized trials
69 downloads medRxiv surgery

Chris Varghese, Sameer Bhat, Tim Hsu-Han Wang, Gregory O'Grady, Sanjay Pandanaboyana

Introduction Delayed gastric emptying (DGE) is frequent after pancreaticoduodenectomy (PD). Several randomised controlled trials (RCTs) have explored operative strategies to minimise DGE, however, the optimal combination of gastric resection approach, anastomotic route, and configuration, role of Braun enteroenterostomy remains unclear. Methods MEDLINE, Embase, and CENTRAL databases were systematically searched for RCTs comparing gastric resection (Classic Whipple, pylorus-resecting, and pylorus-preserving), anastomotic route (antecolic vs retrocolic) and configuration (Billroth II vs Roux-en-Y), and enteroenterostomy (Braun vs no Braun). A random-effects, Bayesian network meta-analysis with non-informative priors was conducted to determine the optimal combination of approaches to PD for minimising DGE. Results Twenty-four RCTs, including 2526 patients and 14 approaches were included. There was some heterogeneity, although inconsistency was low. The overall incidence of DGE was 25.6% (n = 647). Pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy was associated with the lowest rates of DGE and ranked the best in 35% of comparisons. Classic Whipple, retrocolic, Billroth II with Braun ranked the worst for DGE in 32% of comparisons. Pairwise meta-analysis of retrocolic vs antecolic route of gastro-jejunostomy found increased risk of DGE with the retrocolic route (OR 2.1, 95% CrI; 0.92 - 4.7). Pairwise meta-analysis of Braun enteroenterostomy found a trend towards lower DGE rates with Braun compared to no Braun (OR 1.9, 95% CrI; 0.92 - 3.9). Having a Braun enteroenterostomy ranked the best in 96% of comparisons. Conclusion Based on existing RCT evidence, a pylorus-resecting, antecolic, Billroth II with Braun enteroenterostomy may be associated with the lowest rates of DGE.

19: Tissue Stress from Laparoscopic Grasper Use and Bowel Injury in Humans: Establishing Intraoperative Force Boundaries
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Posted 23 Feb 2021

Tissue Stress from Laparoscopic Grasper Use and Bowel Injury in Humans: Establishing Intraoperative Force Boundaries
65 downloads medRxiv surgery

Amanda Farah Khan, Matthew Kenneth MacDonald, Catherine Streutker, Corwyn Rowsell, James Drake, Teodor Grantcharov

BackgroundInappropriate force in laparoscopic surgery can lead to inadvertent tissue injury. It is currently unknown however at what magnitude of compressive stress trauma occurs in gastrointestinal tissues. MethodsThis study included 10 small bowel and 10 colon samples. Each was compressed with pressures ranging from 100 kPa to 600 kPa by a novel device to induce compressive "grasps" to simulate those of a laparoscopic grasper. Experimentation was performed ex-vivo, in-vitro. Grasp conditions of 0 to 600 kPa for a duration of 10 seconds were utilized. Two pathologists who were blinded to all study conditions, performed a histological analysis of the tissues. Patients were eligible if their surgery procured healthy tissue margins for experimentation (a convenience sample). 26 patient samples were procured; six samples were unusable. 10 colon and 10 small bowel samples were tested for a total of 120 experimental cases. No patients withdrew their consent. Two metrics of damage were quantified: an intestinal layer thickness calculation where the serosa layer was measured in the area of compression and compared to a local control and a histological scoring scale for tissue trauma. ResultsSmall bowel (10), M:F was 7:3, average age was 54.3 years. Colon (10), M:F was 1:1, average age was 65.2 years. All 20 patients experienced a significant difference (p<0.05) in serosal thickness post-compression at both 500 and 600 kPa for both tissue types. A logistic regression analysis with a sensitivity of 100% and a specificity of 84.6% on a test set of data predicts a safety threshold of 329-330 kPa. ConclusionA threshold was discovered that corresponded to both significant serosal thickness change and a positive histological trauma score rating. This "force limit" could be used in novel sensorized laparoscopic tools to avoid intraoperative tissue injury.

20: Effects of Acute Normovolemic Hemodilution on Post-Cardiopulmonary Bypass Coagulation Tests and Allogeneic Blood Transfusion in Thoracic Aortic Repair Surgery: An Observational Cohort Study
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Posted 03 Jun 2021

Effects of Acute Normovolemic Hemodilution on Post-Cardiopulmonary Bypass Coagulation Tests and Allogeneic Blood Transfusion in Thoracic Aortic Repair Surgery: An Observational Cohort Study
63 downloads medRxiv surgery

Domagoj Mladinov, Kyle W Eudailey, Luz A Padilla, Joseph B Norman, Benjamin Leahy, Jacob Enslin, Keli L Parker, Katherine F Cornelius, James E Davies

Background and Aim: Perioperative blood transfusion is associated with increased morbidity and mortality. Acute normovolemic hemodilution (ANH) is a blood conservation strategy associated with variable success, and rarely studied in more complex cardiac procedures. The study aim was to evaluate whether acute ANH improves coagulopathy and reduces blood transfusions in thoracic aortic surgeries. Methods: Single-center observational cohort study comparing ANH and standard institutional practice in patients who underwent thoracic aortic repair from 2019 to 2021. Results: 89 patients underwent ANH and 116 standard practice. There were no significant differences between the groups in terms of demographic or major perioperative characteristics. In the ANH group coagulation tests before and after transfusion of autologous blood showed decreased INR and increased platelets, fibrinogen, all with p<0.0005. Coagulation results in the ANH and control groups were not statistically different. The average number of transfused allogeneic products per patient was lower in the ANH vs control group: FFP 1.1 +/-1.6 vs 1.9 +/-2.3 (p=0.003), platelets 0.6 +/-0.8 vs 1.2 +/-1.3 (p=0.0008), and cryoprecipitate 0.3 +/-0.7 vs 0.7 +/-1.1 (p=0.008). Reduction in RBC transfusion was not statistically significant. The percentage of patients who received any transfusion was 53.9% in ANH and 59.5% in the control group (p=0.42). There was no significant difference in major adverse outcomes. Conclusions: ANH is a safe blood conservation strategy for surgical repairs of the thoracic aorta. Laboratory data suggests that ANH can improve coagulopathy after separation from CPB, and significantly reduce the number of transfused FFP, platelets and cryoprecipitate.

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