[Approaches to the pre-operative functional assessment of patients with lung cancer and preoperative rehabilitation]

Surgery is the best treatment for early lung cancer but requires a preoperative functional evaluation to identify patients who may be at a high risk of complications or death. Guideline algorithms include a cardiological evaluation, a cardiopulmonary assessment to calculate the predicted residual lung function, and identify patients needing exercise testing to complete the evaluation. According to most expert opinion, exercise tests have a very high predictive value of complications. However, since the publication of these guidelines, minimally-invasive surgery, sublobar resections, prehabilitation and enhanced recovery after surgery (ERAS) programmes have been developed. Implementation of these techniques and programs is associated with a decrease in postoperative mortality and complications. In addition, the current guidelines and the cut-off values they identified are based on early series of patients, and are designed to select patients before major lung resection (lobectomy-pneumonectomy) performed by thoracotomy. Therefore, after a review of the current guidelines and a brief update on prehabilitation (smoking cessation, exercise training and nutritional aspects), we will discuss the need to redefine functional criteria to select patients who will benefit from lung surgery.

Clinically significant incidental findings during preoperative computed tomography of patients undergoing cardiac surgery

With the development of minimally invasive cardiac surgery, chest and abdominal computed tomography (CT) scans are becoming an integral part of preoperative assessment and planning. Therefore, the number of incidental findings (IFs) detected with CT is rising. We aimed to investigate the frequency of clinically significant IFs on chest and abdominal CT scans performed during the preoperative assessment of patients undergoing adult cardiac surgery in a 2-year period. In a cohort of 401 patients (mean age 67.4 ± 12.3, female gender 28.9%, median logistic EuroSCORE 5.8 [0.9, 90.5]) who underwent chest or abdominal CT imaging during the study period, we identified 75 patients (18.7%) with clinically significant IFs who needed a further treatment or work-up to confirm the diagnosis or postoperative follow-up. Our data indicate that clinically significant IFs in patients referred for cardiac surgery are frequent. It is important to identify clinically significant Ifs, as a clear postoperative follow-up plan should be made.

The tibial spine sign does not indicate cartilage damage in the central area of the distal lateral femoral condyle

PURPOSE

A radiographic overlap of the lateral femoral condyle and the lateral tibial spine ('tibial spine sign') might indicate lateral compartment cartilage damage and might be considered a contraindication for unicompartmental knee arthroplasty (UKA). Therefore, the following research questions were asked: (1) does the presence of a 'tibial spine sign' on radiographs correlate with cartilage lesions on the medial aspect of the lateral femoral condyle on corresponding MRIs?; (2) do cartilage lesions on the medial aspect of the lateral femoral condyle indicate cartilage damage in the central area of the distal lateral femur?; and 3) is the 'tibial spine sign' impacted by the degree of varus deformity, the amount of coronal tibiofemoral subluxation or the functional status of the ACL?

METHODS

One hundred consecutive knees with varus OA in 84 patients were prospectively included. The relationship of the lateral femoral condyle and the tibial spine was graded from 0 to 2 based on the degree of overlap on AP standing knee radiographs. On MRI, cartilage on the medial aspect of the lateral femoral condyle was assessed. Cartilage in the weight-bearing area of the distal lateral femur was analysed according to the OARSI system.

RESULTS

The 'tibial spine sign' assessment correlated well with the degree of cartilage damage on the medial aspect of the lateral condyle (r_s = 0.7, p < 0.001) but did not impact histological OARSI grades in the central weight bearing area of the lateral condyle (n.s.). Mechanical varus and tibiofemoral subluxation were not associated (n.s.) with a positive tibial spine sign. Knees with suggestive ACL insufficiency on MRI had more often a positive tibial spine sign; however, this difference was not statistically significant (n.s.).

CONCLUSION

A positive tibial spine sign does not indicate histologic cartilage damage in the central area of the distal lateral femur and may not be considered a contraindication for medial UKA.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Why women are not small men: sex-related differences in perioperative cardiopulmonary exercise testing

Background

The use of preoperative cardiopulmonary exercise testing (CPET) to evaluate the risk of adverse perioperative outcomes is increasingly prevalent. CPET-derived information enables personalised perioperative care and enhances shared decision-making. Sex-related differences in physical fitness are reported in non-perioperative literature. However, little attention has been paid to sex-related differences in the context of perioperative CPET.

Aim

We explored differences in the physical fitness variables reported in a recently published multi-centre study investigating CPET before colorectal surgery. We also report the inclusion rate of females in published perioperative CPET cohorts that are shaping guidelines and clinical practice.

Methods

We performed a post hoc analysis of the trial data of 703 patients who underwent CPET prior to major elective colorectal surgery. We also summarised the female inclusion rate in peer-reviewed published reports of perioperative CPET.

Results

Fitness assessed using commonly used perioperative CPET variables—oxygen consumption at anaerobic threshold (AT) and peak exercise—was significantly higher in males than in females both before and after correction for body weight. In studies contributing to the development of perioperative CPET, 68.5% of the participants were male.

Conclusion

To our knowledge, this is the first study to describe differences between males and females in CPET variables used in a perioperative setting. Furthermore, there is a substantial difference between the inclusion rates of males and females in this field. These findings require validation in larger cohorts and may have significant implications for both sexes in the application of CPET in the perioperative setting.

Preoperative nuclear stress testing in the very old patient population

BACKGROUND

Elderly patients awaiting moderate to high-risk surgery may undergo nuclear stress testing (NST) in order to evaluate their cardiovascular risk. The prognostic utility of such testing in the very elderly (≥ 85 years) has yet to be fully evaluated. Octogenarians and nonogenarians frequently have a number of concurrent conditions including a high rate of coronary disease, and therefore the prognostic value of NST for their preoperative risk assessment has been questioned. Our evaluation assesses the ability of nuclear stress testing to predict peri-operative cardiac outcomes in this patient population.

AIM

To investigate the ability of NST to predict peri-operative cardiac outcomes in elderly patients awaiting moderate to high-risk surgery.

METHODS

Patients ≥ 85 years undergoing pre-operative NST were retrospectively evaluated. Patients undergoing low-risk surgery were excluded. Major adverse cardiac events (MACE) were considered any adverse event that occurred prior to discharge and included acute heart failure, arrhythmia, acute myocardial infarction, unstable angina, or death. Associations between patient risk factors, MACE, and the obtained results of the pre-operative stress testing, ejection fraction (< 40% or ≥ 40%), summed stress score (≤ 8, ≥ 9), and the summed difference score (≤ 0, > 0) were analyzed.

RESULTS

A total of 69 patients (mean age 88 ± 2.6 years, 31 males) underwent nuclear stress testing prior to surgery. There were 41 (60%) patients found to have an abnormal NST. Sixteen (23%) patients were noted to experience post-operative MACE. No significant associations between risk factors and MACE were noted. Patients with an abnormal NST and/or a summed stress score ≥ 9 were significantly (P < 0.01) more likely to develop peri-operative MACE.

CONCLUSION

Indicated preoperative NST is useful to assess pre-operative risk in elderly patients ≥ 85 years undergoing moderate to high-risk surgery.

Preoperative assessment organization in the time of the outbreak COVID-19

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Maintaining the health of clinical workforce during COVID-19 pandemic is a top priority.

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Extraordinary measures could greatly reduce the risk of cross-contamination for both staff and non-infected patients.

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Airway assessment is a critical time for the consultant anesthetist.

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Projecting the airway examination via a mirror can be a useful idea to minimizing viral contamination.

Preoperative bedside ultrasound assessment of gastric volume and evaluation of predisposing factors for delayed gastric emptying: a case-control observational study

Perioperative pulmonary aspiration of gastric content is a serious complication. Fasting guidelines try to ensure an empty stomach before intervention. Certain medications or pathologies may cause delayed gastric emptying. Bedside ultrasonography is a useful tool when gastric content status is unclear or in emergency situations where fasting is not feasible. The aim of this prospective case-control observational study was to assess differences in gastric fluid volume between fasted patients with or without predisposing factors for delayed gastric emptying. Patients were preoperatively scanned. Antral cross-sectional area was measured by two tracing methods and total gastric clear fluid volumes were calculated. Data was recorded from September 2018 to March 2019 in a university hospital setting in Barcelona, Spain. Fifty-three patients were enrolled, 23 with delayed gastric emptying predisposing factors (DGEF) and 30 without non-DGEF. Ultrasound-estimated gastric clear fluid volume was 35.21 ± 32.69 mL in the DGEF versus 53.50 ± 30.72 mL in the non-DGEF group (p = 0.08). Average volume per unit of weight was 0.61 ± 0.46 mL/kg. Only 1 patient in the DGEF group had a volume that posed a higher risk of aspiration (1.57 mL/kg). Perfect correlation (R = 0.91; p < 0.01) and concordance (0.91; 95% CI 0.83; 0.95) was found between tracing methods. Minimal gastric content was observed in scheduled surgery in spite of predisposing factors for delayed gastric emptying. Ultrasound clear gastric volume estimation was useful to assess preoperative bedside gastric content.

[Perioperative management of polymedication in geriatric patients: risk reduction and coordination with the family practitioner]

The increasing proportion of older and polymorbid people in the population also means an increase in polymedication and its risks. This places new and complex demands on the interdisciplinary and transsectoral collaboration. The preoperative, perioperative and postoperative management of polymedication is described in the article with respect to frequent risks and the chances of a systematic exchange of information. The establishment of an interdisciplinary admission routine in departments of surgery and communication with the family practitioner is crucial for patient safety.

Comparison of Postoperative Pulmonary Complication Indices in Elective Abdominal Surgery Patients

BACKGROUND

Postoperative pulmonary complications (PPC) are important problems that prolong hospital stays by increasing morbidity and mortality of patients. Early identification of risky cases through preoperative evaluation is important for reducing the complications that may be seen in patients postoperatively. The aim of this study is to calculate, evaluate and compare the risk indices for PPC in patients who will undergo elective abdominal surgery.

MATERIALS AND METHODS

One hundred twenty-four patients who were hospitalized for elective abdominal surgery were included in this prospective observational study. American Society of Anesthesiologists (ASA), Epstein and Shapiro scores, respiratory failure index (RFI), pneumonia risk indexes (PI) and scores were calculated preoperatively. Patients were re-evaluated at the 48th postoperative hour, and one-week follow-up was performed. The patients with PPCs are recorded.

RESULTS

The mean PPC rate was 36.8%. Based on this, pleural effusion was observed in 18.5%, prolonged mechanical ventilation in 8.9%, atelectasis in 9.7%, and respiratory failure in 5.7%, bronchospasm in 4.0%, and pneumonia in 3.2% of patients. An increased risk in PPC was determined if ASA were above 3 (odds ratio, [OR], 7.06; <0.001), PI scores were above 3 (OR, 6.67; <0.001), RFI score were above 4 (OR, 6.30, p:0.001) and Shapiro score above 2 (OR, 20.01; <0.001), respectively.

CONCLUSION

The Shapiro index is the strongest predictor of pulmonary complications, whereas the PI is the strongest predictor of morbidity risk. However, RFI and the PI are equally valuable for predicting respiratory complications and may prove to be useful in abdominal surgeries for preoperative assessment.

Acute kidney injury: a risk scoring system for general surgical patients

This article describes the development of a scoring system for general surgical patients to highlight those at greater risk of developing acute kidney injury (AKI). Following a search of the literature on current practice, a list of common variables was composed. Hospital Episode Statistics (HES) data from two random hospital trusts was used. With the help of a risk analysis system (CRAB Medical module, CRAB Clinical Informatics Ltd) it was possible to examine the relationship between potential risk factors and the incidence of AKI. Using Analyse-it for Excel a binary logistic model was created, which led to the development of a logistic regression equation and consequently a scoring system. The sensitivity and specificity of the model was tested using the receiver operating characteristic (ROC) curve. There was good correlation across the whole risk spectrum with an area under ROC curve of 0.806 (95% confidence intervals 0.787-0.825). The scoring system was developed into an admission checklist for general surgical patients to highlight a patient's risk of developing AKI. In a ward setting a checklist that immediately assesses the patient and produces a rapid indication as to whether the patient is at high risk or low risk would seem to be the ideal tool.

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Focused cardiac ultrasound (FoCUS)—a simplified, qualitative version of echocardiography—is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20–30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

Role of a digital tool in preoperative lung resection surgery assessment

The assessment of patients likely to undergo lung resection surgery is a multidisciplinary approach involving pulmonologists, surgeons and anaesthesiologists. In thoracic surgery, medical operability is also a calculation of postoperative lung function. A mobile application – PreParAPP MSD – to calculate postoperative lung function has been developed with the endorsement of the Italian Society of Anaesthesia, Analgesia and Intensive Care and with the unconditional support of MSD Italia. Thanks to a simple graphic interface, the calculation becomes fast and intuitive, while the possibility of storing and sharing data in an analytical and computerised way with other clinicians might help with the full assessment of patients without forcing them to undergo several medical examinations. These simple calculated parameters are performed by a minority of clinicians, generally anaesthesiologists. In our facility, there is a team involved in the perioperative evaluation of lung resection surgery (13 pulmonologists, 9 surgeons and 5 anaesthesiologists). In order to evaluate the possible Awareness towards postoperative lung function calculation better, we organised an internal survey with 27 clinicians who are members of such a team before and after the introduction of the PreParAPP MSD. It was found that after the introduction of PreParAPP MSD, the percentage of clinicians involved in postoperative lung function calculation rose from 18% to 70%. The implementation of a digital tool may help to improve guideline adherence, in accordance with other experiences in which such tools represented the start for various quality improvement purposes throughout the medical field.

Additive value of split-bolus single-phase CT scan protocol for preoperative assessment of lung cancer patients referred for video-assisted thoracic surgery

We aimed to assess the additive value of the split-bolus single-phase computed tomography (CT) scan protocol to preoperatively assess patients with lung cancer, who were referred for video-assisted thoracic surgery, when compared to a standard staging CT protocol. We included 160 patients with lung cancer who underwent a split-bolus single-phase CT scan protocol (split-bolus protocol), which can acquire whole-body staging CT and pulmonary artery-vein separation CT angiography (PA-PV CTA) in a single acquisition and 160 patients who underwent whole-body staging CT (standard protocol). We compared the quality of the staging CT images of hepatic parenchyma, portal vein, and hepatic vein between both protocols. We also investigated image quality on PA-PV CTA images in the split-bolus protocol and recorded the number of patients that underwent the 3D PA-PV CTA imaging process. The split-bolus protocol for staging CT images demonstrated a slightly higher enhancement with regard to the hepatic parenchyma (p = 0.007) and hepatic vein (p = 0.006) than the standard protocol. There was no significant difference in the quality of the staging CT images between both protocols (p = 0.067). The mean CT number for the main pulmonary artery and the left atrium for the PA-PV CTA images in the split-bolus protocol were 289.1 HU and 172.8 HU, respectively. Among the images associated with the split-bolus protocol, 98.1% were of appropriate quality for 3D PA-PV CTA imaging. The split-bolus protocol is a dose-efficient protocol to acquire the staging CT and PA-PV CTA images in a single session and provides sufficient image quality for preoperative assessment in patients with lung cancer.

Use of magnetic resonance index of activity (MaRIA) in the preoperative assessment of small bowel Crohn's disease

BACKGROUND

Accurate quantification of the inflammatory activity in Crohn's Disease is essential to determine adequate treatment for each patient. The aim of the present study is to assess the correlation between the pre-operative Magnetic Resonance Index of Activity (MaRIA) and the histologic degree of inflammation from surgically resected intestinal Crohn's Disease lesions.

METHODS

This is a prospective study including a consecutive case series of patients with small bowel Crohn's Disease, who underwent surgical resection. Magnetic resonance enterography was performed in the 3months prior to surgery, applying a pre-established protocol. Relative contrast enhancements, wall thickness, presence of edema or ulcerations were the parameters used to calculate the MaRIA Index. All patients underwent surgery and every specimen was analyzed. The modified Chiorean classification was applied for the histological analysis and an ordinal regression analysis was used to correlate MaRIA and the grade of inflammation for each lesion.

RESULTS

59 lesions from 35 different patients were analyzed. The degree of inflammation of the lesions was statistically correlated to the MaRIA values (P=.002). The MaRIA index was significantly different (P<.001) between the different histological types of the Crohn's Disease lesions (inflammatory/ fibrotic). The best cut-off for detecting severe inflammation using MaRIA was 20 (AUC: 0.741; 74.1% sensitivity and 78.1% specificity).

CONCLUSION

MaRIA is a reliable tool to distinguish inflammatory from fibrotic lesions. Therefore, it could be considered essential for determining the most appropriate Crohn's Disease treatment for each patient.

[Three-dimensional visual assessment and virtual reality study of centrally located hepatocellular carcinoma on the axis of blood vessels]

Objective: To explore a novel method for preoperative precision assessment of centrally located hepatocellular carcinoma(HCC) with blood vessel as axis based on three-dimensional(3D) visualization and virtual reality(VR) technology and its application values. Methods: High-quality thin-layer enhanced CT data were collected from 20 patients with centrally located HCC who treated at First Department of Hepatobiliary Surgery, Zhujiang Hospital, Southern Medical University from March 2017 to August 2018 diagnosed by preoperative examination. There were 18 males and 2 females, aged 28 to 69 years, all of Child-Pugh grade A. First of all, 3D reconstruction was performed by a 3D visualization software; then, the reconstructed 3D image was imported into VR development engine for VR research; afterwards, the analysis and evaluation system with blood vessel as axis was established based on 3D visualization classification of centrally located HCC; therefore, the relationship of the tumor to its major peripheral blood vessels was accurately judged and the surgical planning was formulated. Two images were brought into the operating room for navigation in surgery. The assessments results of preoperative data (CT and (or) MRI) and three-dimensional visualization of blood vessels in VR environment were compared; the values of the preoperative and postoperative hemoglobin, serum albumin and bilirubin were recorded and compared. Chi-square test, t-test and non-parametric test were used for the analysis of counting data, continuous measurement data and non-normal distribution measurement data, respectively. Results: 3D visualization modeling was completed in all of the 20 patients with centrally located HCC. According to the results of 3D visualization classification of centrally located HCC, there were 3 cases of type Ⅰ,1 case of type Ⅱ,4 cases of type Ⅲ,7 cases of type Ⅳ and 5 cases of type Ⅴ; according to the assessment and classification based on blood vessel as the axis, there were 6 cases of type Ⅰa,2 cases of type Ⅰb,2 cases of type Ⅱa,9 cases of type Ⅱb and 1 case of type Ⅱc. All patients underwent successful resection of tumor under the guidance of 3D visualization and VR technology. There were 15 cases whose assessment results based on preoperative CT/MRI were consistent with intraoperative findings, with a coincidence rate of 75.0%(15/20); while in VR environment, the assessment results of 3D visualization with blood vessel as axis were all consistent with the intraoperative findings, with coincidence rate of 100%(20/20). There was a statistically significant difference between the groups (χ(2)=5.714, P=0.017). There was no red blood cell transfusion in all patients during the operation. The preoperative hemoglobin was (128.8±14.9)g/L, and it was (119.8±12.5)g/L on postoperative day 1. There was no significant difference between these two sets of data (t=2.07, P=0.054). No death during the perioperative period and no complications such as hepatic failure, hemorrhage and biliary fistula after operation occurred. Conclusion: Preoperative evaluation based on 3D visualization and VR technology with blood vessel as the axis has significant clinical value for preoperative planning and surgical navigation of centrally located HCC.

Valoración preoperatoria en cirugía no cardiaca: un abordaje por pasos

Preoperative assessment in non-cardiac surgery is essential to reducing the rate of in-hospital complications. Its purpose is to identify patients with higher levels of risk. Preoperative assessment should not be restricted to cardiovascular aspects, but it should focus on all organs and systems and include medication reconciliation. The purpose of this article is to approach the performance of a preoperative assessment in non-cardiac surgery from the perspective of the internist, with the purpose to help prevent adverse events and improve the overall outcome.

Ludwig's Angina: Anesthetic Management

Ludwig's angina (LA) is a gangrenous cellulitis of the neck that spreads via continuity of the fascial planes. Treatment of LA includes aggressive antibiotic therapy as well as surgical drainage in many cases. The most common cause of infection is odontogenic and can be due to both aerobic and anaerobic bacteria. Signs and symptoms of LA include bilateral cervical swelling, dysphagia, drooling, neck tenderness, elevation and posterior distension of the tongue, restricted neck movement, trismus, dyspnea, and stridor, which can result in difficult airway management. Proper preoperative assessment of patients with LA should include identifying features that may cause difficulties with mask ventilation, direct laryngoscopy, and intubation. Alternative methods of ventilation should be considered and immediately accessible, including a plan on how and when they would be used in the event that a patient cannot be mask ventilated or intubated. Marking external anatomical airway landmarks prior to manipulating the airway can save vital time if an emergent airway becomes necessary.

Surgical attitudes toward preoperative breast magnetic resonance imaging in women with early-stage breast cancer

Background

Preoperative breast magnetic resonance imaging (mri) is commonly requested by surgeons in the initial workup of women with breast cancer; however, its use is controversial. We performed a survey of breast cancer surgeons across Canada to investigate current knowledge about, attitudes to, and self-reported use of preoperative breast mri in a publicly funded health care system in light of the limited evidence to support it.

Methods

All identified general surgeons in Canada were mailed a survey instrument designed to probe current practice and knowledge of published trials.

Results

Of 403 responding surgeons, 233 (58%) indicated that they performed breast cancer surgery. Of those 233, 218 (94%) had access to breast mri and completed the entire survey. Overall, 54.6% of responding surgeons felt that breast mri was useful in surgical planning, and more than half (58.3%) indicated that their frequency of use was likely to increase over the next 5 years. Surgeons found preoperative mri most useful in detecting mammographically occult disease (71.5% of respondents) and in planning for breast-conserving surgery (57.3%). The main limitations reported were timely access to mri (51%) and false positives (36.7%). Responses suggest a knowledge gap in awareness of published trials in breast mri.

Conclusions

Our study found that, in early-stage breast cancer, self-reported use of mri by breast cancer surgeons in Canada varied widely. Reported indications did not align with published data, and significant gaps in self-reported knowledge of the data were evident. Our results would support the development and dissemination of guidelines to optimize use of mri.

Preoperative Evaluation for Ambulatory Anesthesia: What, When, and How?

Most surgery in the United States occurs in offices, free-standing surgicenters, and hospital-based outpatient facilities. Patients are frequently elderly with comorbidities, and procedures are increasingly complex. Traditionally, patients have been evaluated on the day of surgery by anesthesia providers. Obtaining information on patients' health histories, establishing criteria for appropriateness, and communicating medication instructions streamline throughput, lower cancellations and delays, and improve provider and patient satisfaction. Routine testing does not lower risk or improve outcomes. Evaluating and optimizing patients with significant diseases, especially those with suboptimal management, has positive impact on ambulatory surgery and anesthesia.

Peritoneal MRI in patients undergoing cytoreductive surgery and HIPEC: History, clinical applications, and implementation

MR imaging provides considerable advantages in the evaluation of patients with peritoneal metastases. A standardized peritoneal MRI protocol, including diffusion-weighted and gadolinium-enhanced sequences, allows an efficient exploration of small peritoneal tumors that are often missed on other imaging tests. In experienced hands, a dedicated reading allows producing a quantitative and qualitative evaluation of lesional localization to better assist surgeons in the selection of candidates for curative surgery by evaluating the possibility of complete resection, and to plan the surgical procedure. Based on a close collaboration between oncologic surgeon and radiologist, MRI provides a powerful tool for accurate preoperative imaging in patients being considered for curative surgery but also in their surveillance to detect an early recurrence.

Measuring Projection of Nasal Tip with Syringe in Rhinoplasty

Preoperative and intraoperative assessments are very important for surgeons to plan or regulate tip projection. But how to measure the tip projection is a difficult problem even with a ruler or on full-size pictures. In this paper, the author introduces a method to measure the nasal tip projection with a remodeled syringe.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

The evidence-based preoperative assessment for the otolaryngologist

There is a narrow window of opportunity between surgical scheduling and the operative date to optimize patients for an elective surgical procedure. Traditionally, preoperative care has involved extended routine testing batteries with intermittent referrals for medical clearance. These traditions are costly, inefficient, and yield no clear reduction in perioperative morbidity and mortality. Evidence, which has evolved over the past decade, suggests that optimal preoperative care requires a patient-centric, personalized, and often multidisciplinary approach. We present an up-to-date overview of this literature with a focus on the otolaryngologic surgical population. An algorithmic approach to preoperative patient assessment is also proposed in hopes of both optimizing patient outcome and streamlining routine clinical workflow. Laryngoscope, 130:38-44, 2020.

Effectiveness and safety of tranexamic acid in total joint arthroplasty

Total joint arthroplasty is associated with significant blood loss, that could result in the need of blood transfusions. Several techniques are being utilised to limit the volume of blood loss, in order to avoid transfusion. In this review, we look at blood loss in total joint arthroplasty and the perioperative strategies to limit the loss of blood. With the use of tranexamic acid gaining popularity, we analyse the published literature on its use in patients undergoing total joint arthroplasty. We have found that published studies favour using tranexamic acid in total joint arthroplasty as a safe and effective method of reducing blood loss.

Clinical outcomes of laparoscopic cholecystectomy in elderly patients after preoperative assessment and optimization of comorbidities

Backgrounds/Aims

Early laparoscopic cholecystectomy is considered as the standard treatment of acute cholecystitis. However, whether this procedure is desirable in elderly patients with acute cholecystitis is not clearly elucidated. In this study, we aimed to evaluate the effects of thorough preoperative assessment and consultation for complications on clinical outcomes in elderly patients over 65 and over 80 years.

Methods

We retrospectively analyzed 205 patients who were diagnosed with acute cholecystitis between January 2010 and April 2018. The patients were assigned to three groups: group A (aged <65 years), group B, (aged between 65 and 79 years), and group C (aged >79 years). Laparoscopic cholecystectomy was performed after preoperative evaluation, such as echocardiography, pulmonary function test, and consultation about past history.

Results

Significant differences were not found in the complication rate among the age groups. Open conversion was required in eight of the 114 patients in group A, seven of the 70 patients in group B, and one of the 21 patients in group C. However, no statistical significance was found. Moreover, no difference was noted in the start of the meal and the period from surgery to last visit, but hospital stay after surgery was longer in groups b and c.

Conclusions

When sufficient preoperative assessment and treatment were performed, complication and conversion rates were not significantly different among the age groups. In extremely elderly patients, preoperative evaluation and elective laparoscopic cholecystectomy were desirable.

Preoperative Preparations for Enhanced Recovery After Surgery Programs: A Role for Prehabilitation

Preoperative risk assessment is valuable only if subsequent targeted optimization of patient care is allowed. Early assessment of high-risk surgical patients is essential to facilitate appropriate optimization. Preoperative assessment and optimization should not be exclusively focused on patients' comorbidities, but also include nutritional assessment, functional capacity, and promote healthy life style habits that affect surgical outcomes (eg, smoking cessation); it requires a multidisciplinary approach.

Comprehensive Preoperative Assessment and Global Optimization

To successfully deliver greater perioperative value-based care and to effectively contribute to sustained and meaningful perioperative population health management, the scope of existing preoperative management and its associated services and care provider skills must be expanded. New models of preoperative management are needed, which rely extensively on continuously evolving evidence-based best practice, as well as telemedicine and telehealth, including mobile technologies and connectivity. Along with conventional comorbidity optimization, prehabilitation can effectively promote enhanced postoperative recovery. This article focuses on the opportunities and mechanisms for delivering value-based, comprehensive preoperative assessment and global optimization of the surgical patient.

Modern work-up and extended resection in perihilar cholangiocarcinoma: the AMC experience

AIM

Perihilar cholangiocarcinoma (PHC) is a challenging disease and requires aggressive surgical treatment in order to achieve curation. The assessment and work-up of patients with presumed PHC is multidisciplinary, complex and requires extensive experience. The aim of this paper is to review current aspects of diagnosis, preoperative work-up and extended resection in patients with PHC from the perspective of our own institutional experience with this complex tumor.

METHODS

We provided a review of applied modalities in the diagnosis and work-up of PHC according to current literature. All patients with presumed PHC in our center between 2000 and 2016 were identified and described. The types of resection, surgical techniques and outcomes were analyzed.

RESULTS AND CONCLUSION

Upcoming diagnostic modalities such as Spyglass and combinations of serum biomarkers and molecular markers have potential to decrease the rate of misdiagnosis of benign, inflammatory disease. Assessment of liver function with hepatobiliary scintigraphy provides better information on the future remnant liver (FRL) than volume alone. The selective use of staging laparoscopy is advisable to avoid futile laparotomies. In patients requiring extended resection, selective preoperative biliary drainage is mandatory in cholangitis and when FRL is small (< 50%). Preoperative portal vein embolization (PVE) is used when FRL volume is less than 40% and optionally includes the left portal vein branches to segment 4. Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) as alternative to PVE is not recommended in PHC. N2 positive lymph nodes preclude long-term survival. The benefit of unconditional en bloc resection of the portal vein bifurcation is uncertain. Along these lines, an aggressive surgical approach encompassing extended liver resection including segment 1, regional lymphadenectomy and conditional portal venous resection translates into favorable long-term survival.

[Value of three-dimensional visualization technology in preoperative evaluation of liver autotransplantation for end-stage hepatic alveolar echinococcosis]

OBJECTIVE

To evaluate the value of the three-dimensional visualization technology for the preoperative assessment of liver autotransplantation for end-stage hepatic alveolar echinococcosis.

METHODS

A total of 8 patients with end-stage hepatic alveolar echinococcosis undergoing liver autotransplantation in Qinghai Provincial People's Hospital from May 2013 to July 2017 were collected. All cases received preoperative abdominal CT scanning and dynamic three-phase enhanced CT scanning, and the original CT data were transferred to the human 3D visualization virtual surgical planning system. The volumes of Echinococcus multilocularis and pre-resected liver were measured using the 3D visualization reconstruction, and the relationship between the lesion and the neighboring tissues was observed. The value of the 3D visualization technology for the preoperative assessment of liver autotransplantation for end-stage hepatic alveolar echinococcosis was assessed by comparing with the intraoperative findings.

RESULTS

The 3D visualization reconstruction model clearly displayed the adjacent relationship between the lesions of end-stage hepatic alveolar echinococcosis and the neighboring tissues, and no significant difference was seen between the pre-resected liver volume in 3D visualization reconstruction model and the actually resected liver volume (t = 1.083, P > 0.05).

CONCLUSIONS

3D visualization technology is feasible to develop a reasonable scheme for liver resection and vascular anastomosis for end-stage hepatic alveolar echinococcosis prior to liver autotransplantation, which may increase the success of surgery and improve the prognosis.

Preoperative Evaluation and Patient Selection for Office-Based Oral Surgery Anesthesia

Provision of an outpatient anesthetic requires careful review of the patient's medical history along with salient aspects of the physical examination. The oral and maxillofacial surgeon may need to consult with the patient's medical providers to gain an understanding of the patient's potential risks for an adverse event. This article reviews key aspects of the patient evaluation so that an informed determination of suitability for an office anesthetic can be made.

Preoperative magnetic resonance imaging predicts eligibility for arthroscopic primary anterior cruciate ligament repair

PURPOSE

To assess the role of preoperative magnetic resonance imaging (MRI) on the eligibility for arthroscopic primary anterior cruciate ligament (ACL) repair.

METHODS

All patients undergoing ACL surgery between 2008 and 2017 were included. Patients underwent arthroscopic primary repair if sufficient tissue length and quality were present, or they underwent single-bundle ACL reconstruction. Preoperative MRI tear locations were graded with the modified Sherman classification: type I (>90% distal remnant length), type II (75-90%), or type III (25-75%). MRI tissue quality was graded as good, fair, or poor. Arthroscopy videos were reviewed for tissue length and quality, and final treatment.

RESULTS

Sixty-three repair patients and 67 reconstruction patients were included. Repair patients had more often type I tears (41 vs. 4%, p < 0.001) and good tissue quality (89 vs. 12%, p < 0.001). Preoperative MRI tear location and tissue quality predicted eligibility for primary repair: 90% of all type I tears and 88% of type II tears with good tissue quality were repaired, while only 23% of type II tears with fair tissue quality, 0% of type II tears with poor tissue quality, and 14% of all type III tears could be repaired.

CONCLUSIONS

This study showed that tear location and tissue quality on preoperative MRI can predict eligibility for arthroscopic primary ACL repair. These findings may guide the orthopaedic surgeon on the preoperative assessment for arthroscopic primary repair of proximal ACL tears.

LEVEL OF EVIDENCE

Level IV.

Does Computed Tomography-Based Virtual Colonoscopy Improve the Accuracy of Preoperative Assessment Based on Magnetic Resonance Imaging in Women Managed for Colorectal Endometriosis?

STUDY OBJECTIVE

To evaluate whether combining computed tomography-based virtual colonoscopy (CTC) with magnetic resonance imaging (MRI) improves preoperative assessment of colorectal endometriosis.

DESIGN

Retrospective study using prospectively recorded data (Canadian Task Force classification II-2).

SETTING

University tertiary referral center.

PATIENTS

Seventy-one women treated for colorectal endometriosis managed between June 2015 and May 2016.

INTERVENTIONS

Patients included in our study underwent colorectal surgery for deep endometriosis infiltrating the rectum or the sigmoid colon and had preoperative assessment using MRI and CTC. To establish the correlation between preoperative and intraoperative findings, the concordance kappa index was used.

MEASUREMENTS AND MAIN RESULTS

Preoperative data provided by MRI, CTC, and a combination of both were compared with intraoperative findings. All 71 patients had a total of 105 endometriotic intestinal lesions intraoperatively confirmed. Some 71.2% of rectal nodules and 60.0% of sigmoid nodules infiltrated the muscularis propria of the intestinal wall, with most infiltrating between 25% and 50% of the rectal circumference; 73% of rectal nodules and 96% of sigmoid nodules led to varying degrees of stenosis. The concordance between intraoperative and preoperative findings concerning the presence of rectal nodules was high, at .88 when associating CTC with MRI, whereas each imaging technique taken individually provided lower concordance coefficients. In our study 80.3% of patients underwent the procedure that had been preoperatively planned.

CONCLUSION

Our study suggests that associating MRI with CTC leads to improved accuracy in preoperative assessment of colorectal endometriosis and in subsequent preoperative choice of surgical procedures on the digestive tract.

Cardiopulmonary exercise testing (CPET) in the United Kingdom-a national survey of the structure, conduct, interpretation and funding

Background

Cardiopulmonary exercise testing (CPET) is an exercise stress test with concomitant expired gas analysis that provides an objective, non-invasive measure of functional capacity under stress. CPET-derived variables predict postoperative morbidity and mortality after major abdominal and thoracic surgery. Two previous surveys have reported increasing utilisation of CPET preoperatively in England. We aimed to evaluate current CPET practice in the UK, to identify who performs CPET, how it is performed, how the data generated are used and the funding models.

Methods

All anaesthetic departments in trusts with adult elective surgery in the UK were contacted by telephone to obtain contacts for their pre-assessment and CPET service leads. An online survey was sent to all leads between November 2016 and March 2017.

Results

The response rate to the online survey was 73.1% (144/197) with 68.1% (98/144) reporting an established clinical service and 3.5% (5/144) setting up a service. Approximately 30,000 tests are performed a year with 93.0% (80/86) using cycle ergometry. Colorectal surgical patients are the most frequently tested (89.5%, 77/86). The majority of tests are performed and interpreted by anaesthetists. There is variability in the methods of interpretation and reporting of CPET and limited external validation of results.

Conclusions

This survey has identified the continued expansion of perioperative CPET services in the UK which have doubled since 2011. The vast majority of CPET tests are performed and reported by anaesthetists. It has highlighted variation in practice and a lack of standardised reporting implying a need for practice guidelines and standardised training to ensure high-quality data to inform perioperative decision making.

Preoperative exercise capacity is associated with the prevalence of postoperative delirium in elective cardiac surgery

BACKGROUND

Postoperative delirium (POD) is a critical complication that is closely associated with mortality and major morbidity in elective cardiac surgery. The identification of patients at risk for POD is crucial but has not been fully explored.

AIMS

The aim of this study was to determine the predictive value of the assessment of preoperative exercise capacity for POD.

METHODS

We enrolled 313 consecutive patients (mean age, 68.6 ± 14.8 years) undergoing elective cardiac surgery. We measured physical functions such as the 6-minute walking distance (6MWD) and Timed Up-and-Go test (TUG) before surgery. The assessment of delirium was conducted every 8 h from the day of surgery to 5 days after surgery using the Intensive Care Delirium Screening Checklist.

RESULTS

POD occurred in 46 patients (14.6%). Age, 6MWD, TUG, serum hemoglobin, estimated glomerular filtration rate, and length of intensive care unit stay were significantly different based on the presence or absence of POD (p < 0.05 for each). After multivariate analysis, 6MWD remained a statistically significant indicator for developing POD (OR 0.98; p = 0.02). The cut-off value of 6MWD for predicting POD was 345 m (AUC = 0.75; p = 0.001).

CONCLUSIONS

Poor exercise capacity was found to be an independent predictor of POD following elective cardiac surgery. This finding suggests the importance of preoperative functional evaluation in the prevention and management of POD in cardiac surgery patients.

Reconsideration of frailty in relation to surgical indication

Given that an increasing number of elderly patients are undergoing surgical procedures for a diversity of indications, the concept of frailty is currently being examined in more depth in clinical medicine. Established surgical risk scores designed to predict mortality are mainly focused on general demographic information and clinical factors; however, these do not account for the frailty condition. With vulnerability and low resiliency in the frail elderly, these conventional scores are unable to accurately predict postoperative outcomes including adverse complications, disability, the need for additional rehabilitation, and prolonged length of hospitalization. Over the last decade, it has been demonstrated that frailty is an independent risk factor of surgery and strongly associated with adverse postoperative outcomes and mortality. It is essential today that surgeons assimilate the concept of frailty and the relationship between frailty and surgical outcomes. A preoperative frailty assessment can assist in determining surgical indication and optimal perioperative management, ultimately impacting the postoperative functional state and quality of life. Here we review the validity of preoperative frailty assessments for surgical intervention, possible treatments for frailty, and indicate future directions in this field.

Comparison of risk-scoring systems in the prediction of outcome after liver resection

Background

Risk prediction techniques commonly used in liver surgery include the American Society of Anesthesiologists (ASA) grading, Charlson Comorbidity Index (CCI) and cardiopulmonary exercise tests (CPET). This study compares the utility of these techniques along with the number of segments resected as predictive tools in liver surgery.

Methods

A review of a unit database of patients undergoing liver resection between February 2008 and January 2015 was undertaken. Patient demographics, ASA, CCI and CPET variables were recorded along with resection size. Clavien-Dindo grade III–V complications were used as a composite outcome in analyses. Association between predictive variables and outcome was assessed by univariate and multivariate techniques.

Results

One hundred and seventy-two resections in 168 patients were identified. Grade III–V complications occurred after 42 (24.4%) liver resections. In univariate analysis of CPET variables, ventilatory equivalents for CO₂ (VEqCO₂) was associated with outcome. CCI score, but not ASA grade, was also associated with outcome. In multivariate analysis, the odds ratio of developing grade III–V complications for incremental increases in VEqCO₂, CCI and number of liver segments resected were 1.09, 1.49 and 2.94, respectively.

Conclusions

Of the techniques evaluated, resection size provides the simplest and most discriminating predictor of significant complications following liver surgery.

Clinical significance of chronic obstructive pulmonary disease in patients undergoing elective total arch replacement: analysis based on the Japan Adult Cardiovascular Surgery Database

Objectives

We investigated the impact of chronic obstructive pulmonary disease (COPD) on in-hospital outcomes of patients undergoing conventional total aortic arch replacement (TAR), based on the Japan Adult Cardiovascular Surgery Database.

Methods

A total of 12 590 patients who underwent elective TAR between 2008 and 2013 were retrospectively reviewed. Patients were divided into 4 categories: normal respiratory function (control), with ratio of forced expiratory volume of air in 1 s (FEV 1 ) to forced vital capacity (FVC) of 76% or greater (TAR, n  = 10 040); mild COPD, with FEV 1 /FVC ratio 60-75% and/or use of bronchodilator (TAR, n  = 1890); moderate COPD, FEV 1 /FVC ratio 50 to 59% and/or use of steroids (TAR, n  = 504); and severe COPD, FEV 1 /FVC ratio less than 50% and/or presence of respiratory failure (TAR, n  = 156).

Results

In-hospital mortality was 5.7% (5.2% in controls, 7.0% in mild COPD, 9.3% in moderate COPD and 9.0% in severe COPD). A significant trend towards the severity of COPD was noted ( P  < 0.0001). A higher incidence of postoperative pneumonia (6.0% in control, 11.0% in mild COPD, 12.3% in moderate COPD and 15.4% in severe COPD; P  < 0.0001) and a greater need for prolonged ventilation (17.5% in control, 22.0% in mild COPD, 26.6% in moderate COPD and 29.5% in severe COPD; P  < 0.0001) were observed in cases of more severe COPD. The odds ratio of moderate/severe COPD for in-hospital mortality was 1.44 with confidence interval of 1.08-1.91 ( P  = 0.012).

Conclusions

There was a significant increase in in-hospital mortality and morbidity with increasing severity of COPD in patients who underwent TAR.

Preoperative Assessment for Ambulatory Surgery

PURPOSE OF REVIEW

Ambulatory surgery has grown in recent decades in volume and represents a significant number of anesthetics delivered throughout the USA. Preoperative anesthetic assessment in the ambulatory setting has become important because patients with numerous complex comorbidities are now commonplace in this arena. Disease states involving the lungs, the heart, the kidneys, and subpopulations including those who are obese and the elderly commonly receive anesthetics in an ambulatory setting.

RECENT FINDINGS

This review presents key aspects of current thinking with regard to preoperative assessment and considerations for different critical disease states and subpopulations that are now being managed under ambulatory surgery. Same day surgery centers require patient safety, and expectations are high for patient satisfaction. Advancements in surgical and anesthetic technique have allowed for more complex patients to partake in ambulatory surgery. Anesthesiologists must be familiar with guidelines, state-of-the-art pain management, and standards of preoperative patient evaluation to accurately stratify patient risk and to advocate for patient safety.

Systematic review and retrospective validation of prediction models for weight loss after bariatric surgery

BACKGROUND

Patients often have less than realistic expectations of the weight loss they are likely to achieve after bariatric surgery. It would be useful to have a well-validated prediction tool that could give patients a realistic estimate of their expected weight loss.

OBJECTIVES

To perform a systematic review of the literature to identify existing prediction models and attempt to validate these models.

SETTING

University hospital, United Kingdom.

METHODS

A systematic review was performed. All English language studies were included if they used data to create a prediction model for postoperative weight loss after bariatric surgery. These models were then tested on patients undergoing bariatric surgery between January 1, 2013 and December 31, 2014 within our unit.

RESULTS

An initial literature search produced 446 results, of which only 4 were included in the final review. Our study population included 317 patients. Mean preoperative body mass index was 46.1 ± 7.1. For 257 (81.1%) patients, 12-month follow-up was available, and mean body mass index and percentage excess weight loss at 12 months was 33.0 ± 6.7 and 66.1% ± 23.7%, respectively. All 4 of the prediction models significantly overestimated the amount of weight loss achieved by patients. The best performing prediction model in our series produced a correlation coefficient (R²) of .61 and an area under the curve of .71 on receiver operating curve analysis.

CONCLUSIONS

All prediction models overestimated weight loss after bariatric surgery in our cohort. There is a need to develop better procedures and patient-specific models for better patient counselling.

Integration of Geriatric Assessment in the Care of Patients with Gastrointestinal Malignancies

BACKGROUND

The majority of patients with gastrointestinal (GI) malignancies are older. Recently, it has become evident that elements from a geriatric assessment (GA) are powerful predictors of outcomes such as postoperative morbidity and mortality, length of stay, type of treatment received, and survival across several GI tumor types in older adults. A GA is a systematic evaluation of functional status, comorbidities, polypharmacy, cognition, nutritional status, emotional status, and social support.

METHODS

A PubMed search was performed in order to identify clinical studies investigating the association between GA and outcomes in patients with GI malignancies.

RESULTS

A total of 31 studies were included in this review. For colorectal cancer, the evidence linking GA variables and frailty to negative outcomes is substantial and consistent. The data regarding other GI malignancies is more limited, but generally shows the same findings.

CONCLUSION

Increasing data shows that elements from a GA and frailty are consistently associated with negative short- and long-term treatment outcomes in older patients with GI malignancies. Future studies should investigate the impact of geriatric interventions on outcomes.

Index of convexity: A novel method for assessing liver functional reserve using technetium-99m-galactosyl human serum albumin liver scintigraphy

Preoperative evaluation of liver functional reserve is important in hepatobiliary surgery. Although the indocyanine green retention rate at 15 minutes (ICG-R15) is the gold standard for this purpose, a new method without technical complexity would be preferable. We assessed the usefulness of the previously established index of convexity (IOC). In total, 159 consecutive patients who underwent both technetium-99m-galactosyl human serum albumin (^99mTc-GSA) scintigraphy and the ICG-R15 were included. Correlation coefficients between indices from ^99mTc-GSA scintigraphy and blood examinations including ICG-R15 were evaluated, and a conversion formula from the IOC to the ICG-R15 was established. The IOC was calculated as [L(15) × 2 - L(3) - L(27)] / [L(27) - L(3)], where L(t) indicates the radiation counts within the whole liver at t minutes after ^99mTc-GSA injection. The IOC showed a significantly stronger correlation with the ICG-R15 (r = -0.532, p < 0.001) than the index of blood clearance (HH15) and the receptor index (LHL15). A formula for estimating ICG-R15 from IOC was "ICG-R15 = -31.0 × IOC + 30.1". In conclusion, the IOC is a better index for evaluating preoperative liver functional reserve than the conventional indices. A formula for estimating ICG-R15 from the IOC will be useful.

The Preoperative Assessment and Optimization of Patients Undergoing Major Urological Surgery

PURPOSE OF REVIEW

Improving patient outcomes from major urological surgery requires not only advancement in surgical technique and technology, but also the practice of patient-centered, multidisciplinary, and integrated medical care of these patients from the moment of contemplation of surgery until full recovery. This review examines the evidence for recent developments in preoperative assessment and optimization that is of relevance to major urological surgery.

RECENT FINDINGS

Current perioperative medicine recommendations aim to improve the short-term safety and long-term effectiveness of surgical treatments by the delivery of multidisciplinary integrated medical care. New strategies to deliver this aim include preoperative risk stratification using a frailty index and cardiopulmonary exercise testing for patients undergoing intra-abdominal surgery (including radical cystectomy), preoperative management of iron deficiency and anemia, and preoperative exercise intervention. Proof of the utility and validity for improving surgical outcomes through advances in preoperative care is still evolving. Evidence-based developments in this field are likely to benefit patients undergoing major urological surgery, but further research targeted at high-risk patients undergoing specific urological operations is required.

Rapid Geriatric Assessment of Hip Fracture

A comprehensive geriatric assessment, combined with a battery of imaging and blood tests, should be able to identify those hip fracture patients who are at higher risk of short- and long-term complications. This comprehensive assessment should be followed by the implementation of a comprehensive multidimensional care plan aimed to prevent negative outcomes in the postoperative period (short and long term), thus assuring a safe and prompt functional recovery while also preventing future falls and fractures.

Preoperative Assessment of Risk Factors

Hemostasis is essential during endoscopic sinus and skull base surgery. Patients must be adequately assessed for bleeding risk to appropriately consent to surgery. The patient and the surgeon must be aware of the individual bleeding risk for a given procedure. A thorough history and physical examination is the best screening methodology available to determine whether a patient requires further hematologic work-up. Included in this assessment should be any medications and herbals that the patient consumes. This ensures a safe evaluation of the patient, streamlines appropriate consultation and testing when necessary, and confers accurate surgical risk assessment.

Significant discrepancies exist between clinician assessment and patient self-assessment of functional capacity by validated scoring tools during preoperative evaluation

Background

Preoperative assessment of functional capacity is necessary to direct decisions regarding cardiac evaluation and may help identify patients at high risk for perioperative complications. Patient self-triage regarding functional capacity could be useful for discerning which patients benefit from a clinician evaluation at a Preoperative Evaluation Center prior to the day of surgery. We evaluated the feasibility of preoperative, patient self-triage regarding functional capacity.

Methods

Patients were recruited immediately prior to their preoperative evaluation. Study participants completed electronic versions of the Duke Activity Status Index (DASI) and the Patient-Reported Outcomes Measurement System (PROMIS)–Short Form 12a–Physical Function. DASI and PROMIS questionnaire responses were scored and evaluated for correlation with clinician assessments of functional capacity. Correlation was analyzed around the dichotomous outcome of <4 metabolic equivalents of task (METs) or ≥4 METs. Patients also evaluated the usability of the questionnaires.

Results

After IRB approval, 204 patients were enrolled and completed both DASI and PROMIS questionnaires. Clinicians assessed functional capacity at <4 METs for 109 patients (53.4 %) compared to 18 (8.8 %) patient self-assessments <4 METs as estimated by DASI. These results represent a significant discrepancy between assessments (Fisher’s exact, two-tailed P value <0.0001). The standard T-score of PROMIS estimates of functional capacity correlated with DASI estimates (R² 0.76). The mean and standard deviation for PROMIS T-scores were 43.3 and 9.86, respectively (mean 50.0; SD 10.0 for the general population).

Of the 203 patients who completed the entire study survey, 192 (94.6 %) stated that they did not require assistance from another person, and 187 (94 %) responded either “agree” or “strongly agree” to the DASI questionnaire being “easy to understand” and “easy to complete;” 186 (93 %) and 188 (94 %), respectively, responded similarly to the PROMIS questionnaire.

Conclusions

While both electronic questionnaires were easy to understand and complete for most study participants, there was a significant discrepancy between clinician assessments and patient self-assessments of functional capacity. Further study is needed to determine if either patient self-triage by means of activity questionnaires or clinician evaluation is valid and reliable in the preoperative setting.

Electronic supplementary material

The online version of this article (doi:10.1186/s13741-016-0041-4) contains supplementary material, which is available to authorized users.

Preoperative neuropsychological presentation of patients with refractory frontal lobe epilepsy

BACKGROUND

This study investigated whether certain cognitive deficits are associated with frontal lobe epilepsy (FLE) aiming to contribute with localization data to the preoperative assessment of epilepsy surgery candidates.

METHODS

We evaluated 34 patients with refractory FLE, 37 patients with refractory medial temporal lobe epilepsy (MTLE), and 22 healthy individuals in attention, psychomotor speed, motor function, verbal memory span, verbal fluency, response inhibition/interference, concept formation and set shifting, anticipation and planning, global memory.

RESULTS

Neuropsychological performances of FLE and MTLE were similar, with the only exception the WCST-number of categories index, measuring mental flexibility, in which MTLE patients performed significantly worse than FLE patients. Left-FLE patients presented more perseverative responding compared to both other patient groups and healthy controls (HCs), while left-MTLE patients showed worse sorting abilities than the other epilepsy groups.

CONCLUSIONS

Our findings suggest a weak cognitive differentiation between FLE and MTLE, probably attributed to the intricate nature of fronto-temporal connectivity frequently resulting in overlapping deficits as well as the confounding effects of seizure-related variables. In clinical practice, a highly individualized (idiographic) neuropsychological approach along with the inclusion of concurrent EEG recordings (e.g., interictal coupling) may be of help for neuropsychologists in identifying FLE patients from those with medial temporal pathology presenting frontal dysfunction as a secondary cognitive symptom.

Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy

BACKGROUND

Ultrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology.

OBJECTIVE

To determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies.

MATERIALS AND METHODS

In this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management.

RESULTS

Ultrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting.

CONCLUSION

Ultrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.

Approach to Evaluating the Multimorbid Patient with Cardiovascular Disease Undergoing Noncardiac Surgery

Older patients undergo more inpatient and outpatient procedures than do younger individuals, and their risk of suffering undesired outcomes is greater. The performance of a productive preoperative assessment entails more than the application of the sundry clinical practice guidelines relating to a patient's various medical diagnoses. A better approach involves adoption of a physiologically integrated, whole-person assessment that takes into account the patient's cognitive function, mood, physical function and mobility (including the possibility of frailty), social support, nutritional status, and medication use. This article outlines such an approach and highlights the many gaps in the current evidence base.