Effects of a perioperative smoking cessation intervention on postoperative complications: a randomized trial

Optimizing Outpatient Total Ankle Replacement from Clinic to Pain Management

Outpatient total ankle arthroplasty is a potential significant source of cost savings. The ability to institute an effective outpatient total ankle program depends on appropriate patient selection, surgeon experience with total ankle replacement, addressing preoperative patient expectations, the involvement of an experienced multidisciplinary care team including experienced anesthesiologists, nurse navigators, recovery room nursing staff and physical therapists, and most importantly, such a program requires complete institutional logistical support.

Surgical considerations of marijuana use in elective procedures

BACKGROUND

Marijuana consumption is estimated as upwards of 9.5% of the U.S. adult population. Nevertheless, few trials exist on potential implications for surgical outcomes amongst users.

METHODS

A current literature review explored marijuana's effects to answer: (I) How is marijuana use screened for in clinical and pre-operative settings? (II) What are potential surgical complications of marijuana use? (III) How should surgeons handle patient marijuana use regarding elective surgery? (IV) Are marijuana's effects the same or different from those of tobacco?

RESULTS

In acute settings, marijuana's effects peaked at approximately 1 hour post initiation, lasting 2-4 hours. Marijuana increased cardiac workload, myocardial infarctions and strokes in young, chronic users. Cannabis caused similar pulmonary complications to those of a tobacco smoker. Marijuana caused airway obstruction and increased anesthetic dosages needed to place laryngeal airways. Use within 72 hours of general anesthesia was advised against. In vitro and in vivo studies were contradictory regarding prothrombic or antithrombotic effects.

CONCLUSIONS

Marijuana use is problematic to surgeons, left without evidence-based approaches. In emergency settings, marijuana use may be unavoidable. However, further research would provide much needed information to guide elective procedures.

Factors Influencing Functional Outcomes of Subtalar Fusion for Posttraumatic Arthritis After Calcaneal Fracture

BACKGROUND

Subtalar arthrodesis is a common salvage operation for posttraumatic subtalar arthritis. This study aimed to identify factors associated with functional outcomes and quality of life after subtalar fusion for posttraumatic subtalar arthritis after calcaneal fracture.

METHODS

This is a retrospective study with follow-up by questionnaire in two level 1 trauma centers. Patients who underwent subtalar arthrodesis for posttraumatic arthritis after a calcaneal fracture between 2001 and 2016 were identified and contacted for completion of a survey consisting of the Foot and Ankle Ability Measure (FAAM), Maryland Foot Score (MFS), Patient-Reported Outcomes Measurement System Physical Function (PROMIS PF, Short Form 10a) questionnaire, EuroQol 5-dimensional (EQ-5D) questionnaire, and EuroQol visual analog scale (EQ-VAS). Exclusion criteria were initial subtalar arthrodesis at an outside facility, primary arthrodesis for fracture, initial arthrodesis earlier than 2001, amputation of the fused foot or leg, younger than 18 years at time of fusion, and inability to communicate in English. A total of 159 patients met our inclusion criteria. Eighty-four patients completed the questionnaires, resulting in a response rate of 59%.

RESULTS

Median FAAM score was 79 (interquartile range [IQR], 48-90), median MFS was 74 (IQR, 56-86), and median PROMIS PF was 45 (IQR, 38-51). Quality of life was significantly lower when compared to a reference population ( P = .001). Smoking was independently associated with worse outcomes. Complications after fusion (such as nonunion, implant failure, and infectious complications), high-energy trauma, and ipsilateral injury were also predictors for poorer outcomes.

CONCLUSION

Acceptable functional outcomes and quality of life were observed after subtalar fusion. Smoking, complications after subtalar fusion, high-energy trauma, and presence of ipsilateral injuries were independently associated with worse functionality and quality of life.

LEVEL OF EVIDENCE

Prognostic level III, comparative series.

Complex Ventral Hernias: A Review of Past to Present

With the incidence of ventral hernias increasing, surgeons are faced with greater complexity in dealing with these conditions. Proper knowledge of the history and the advancements made in managing complex ventral hernias will enhance surgical results. This review article highlights the literature regarding complex ventral hernias, including a shift from a focus that stressed surgical technique toward a multimodal approach, which involves optimization and identification of suboptimal characteristics.

[Relationship between cigarette smoking and the carbon monoxide concentration in the exhaled breath with perioperative respiratory complications]

BACKGROUND

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

METHODS

One hundred and fifty two patients (smokers, Group S and non-smokers, Group NS), who underwent laparoscopic cholecystectomies under general anesthesia, were studied. Patients completed the Fagerstrom Test for Nicotine Dependence. The preoperative carbon monoxide level in the exhaled breath levels were determined using the piCO+Smokerlyzer 12h before surgery. Respiratory complications were recorded during induction of anesthesia, intraoperatively, during extubation, and in the recovery room.

RESULTS

Statistically significant increases were noted in group S with respect to the incidence of hypoxia during induction of anesthesia, intraoperative bronchospasm, bronchodilator treatment intraoperatively, and bronchospasm during extubation. The carbon monoxide level in the exhaled breath and the Fagerstrom Test for Nicotine Dependence, and number of cigarettes smoked 12h preoperatively were designated as covariates in the regression model. Logistic regression analysis of anesthetic induction showed that a 1 unit increase in the carbon monoxide level in the exhaled breath level was associated with a 1.16 fold increase in the risk of hypoxia (OR=1.16; 95% CI 1.01-1.34; p=0.038). Logistic regression analysis of the intraoperative course showed that a 1 unit increase in the number of cigarettes smoked 12h preoperatively was associated with a 1.16 fold increase in the risk of bronchospasm (OR=1.16; 95% CI 1.04-1.30; p=0.007). While in the recovery room, a 1 unit increase in the Fagerstrom Test for Nicotine Dependence score resulted in a 1.73 fold increase in the risk of bronchospasm (OR=1.73; 95% CI 1.04-2.88; p=0.036).

CONCLUSIONS

Cigarette smoking was shown to increase the incidence of intraoperative respiratory complications while under general anesthesia. Moreover, the estimated preoperative carbon monoxide level in the exhaled breath level may serve as an indicator of the potential risk of perioperative respiratory complications.

What Is the Impact of Smoking on Revision Total Knee Arthroplasty?

BACKGROUND

There is a paucity of literature evaluating the impact of smoking on revision arthroplasty procedures. The purpose of this study was to identify the effect of smoking on complications after revision total knee arthroplasty (rTKA).

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to identify patients who underwent rTKA between 2006 and 2014. Patients were divided into current smokers and nonsmokers according to the NSQIP definitions. Each cohort was compared in terms of demographic data, preoperative comorbidities, and operative time. Infection end points were created from composite surgical site infection variables defined by the NSQIP database. Multivariate logistic regression analysis was utilized to adjust for confounding variables and calculate adjusted odds ratios (ORs) and associated 95% confidence intervals (95% CIs).

RESULTS

In total, 8776 patients underwent rTKA. Of these patients, 11.6% were current smokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (3.8% vs 1.8%, P < .0001), deep infection (2.5% vs 1.0%, P < .0001), pneumonia (1.3% vs 0.4%, P < .0001), and reoperation (5.0% vs 3.1%, P = .001) compared to nonsmokers undergoing revision total knee arthroplasty. Multivariate analysis identified current smokers as being at a significantly increased risk of any wound complication (OR 2.1; 95% CI 1.4-3.1) and deep infection (OR 2.1, 95% CI 1.2-3.6) after rTKA.

CONCLUSION

This study demonstrates that smoking significantly increases the risk of infection, wound complications, and reoperation after rTKA. The results are even more magnified for revision procedures compared to published effects of smoking on primary total knee arthroplasty complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.

Predictors of lower health-related quality of life after operative repair of diaphyseal femur fractures in a low-resource setting

BACKGROUND

Little data exists on the negative impact of orthopaedic trauma on quality of life (QOL) in low- and middle-income countries (LMICs). The goal of this study is to investigate the factors associated with lower QOL after operative fixation of femoral shaft fractures in adult patients in a low-resource setting.

METHODS

This prospective cohort study followed 272 factures in adults undergoing operative fixation for diaphyseal femur fractures at Tanzania. Patient demographics, injury characteristics, treatment modalities, and functional outcomes up to 1-year post-operatively were evaluated for association with 1-year post-operative EQ-5D QOL scores via univariate linear regression analysis.

RESULTS

EQ-5D values were significantly lower at 1 year than at baseline (0.941 vs 0.991, p < 0.0005).

CONCLUSIONS

Operative fixation of femoral shaft fractures in LMICs results in return to near baseline QOL. Demographic and treatment factors were not significantly associated with EQ-5D. and several markers of recovery were associated with lower 1 year QOL, including pain, knee stiffness, delayed radiographic healing, complications requiring reoperation. Efforts to reduce perioperative complications may help improve post-operative QOL.

What is the Impact of Smoking on Revision Total Hip Arthroplasty?

BACKGROUND

There is a paucity of literature evaluating the impact of smoking on revision total hip arthroplasty (THA) outcomes. The purpose of this study was to identify the effect of smoking on complications after revision THA.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database to identify patients who underwent revision THA between 2006 and 2014. Patients were divided into current smokers and nonsmokers. Each cohort was compared in terms of demographics, preoperative comorbidities, and operative time. Multivariate logistic regression analysis was utilized. Adjusted odds ratios (OR) for the outcomes of any wound complication, deep infection, and reoperation within 30 days of revision THA were calculated.

RESULTS

In total, 8237 patients had undergone a revision THA. Of these patients, 14.7% were current smokers and 85.3% were nonsmokers. Univariate analyses demonstrated that smokers had a higher rate of any wound complication (4.1% vs 3.0%, P = .04), deep infection (3.2% vs 1.9%, P = .003), and reoperation (6.8% vs 4.8%, P = .003). Multivariate analysis controlling for confounding demographic, comorbidity, and operative variables identified current smokers as having a significantly increased risk of deep infection (OR, 1.58; 95% CI, 1.04-2.38) and reoperation (OR, 1.37; 95% CI, 1.03-1.85).

CONCLUSION

Smoking significantly increases the risk of infection and reoperation after revision THA. The results are even more magnified for revision procedures compared to published effects of smoking on primary THA complications. Further research is needed regarding the impact of smoking cessation on mitigation of these observed risks.

Interaction of obesity with smoking and inflammatory arthropathies increases the risk of periprosthetic joint infection: a propensity score matched study in a Chinese Han population

BACKGROUND

Although a large number of studies have identified obesity as an independent risk factor for the development of periprosthetic joint infection (PJI), the synergistic impacts of obesity with other factors on PJI remain unknown. Additionally, few studies have specifically explored the risk factors of PJI within a Chinese population.

AIMS

To investigate the association between obesity and PJI in a Chinese population, and identify synergistic impacts of obesity with other risk factors on the development of PJI.

METHODS

Three hundred and seven patients at a single institution with a diagnosis of PJI following primary total hip or knee arthroplasty, treated from 2008 to 2015, were identified. Each case was matched with two controls who did not develop PJI after primary total hip or knee arthroplasty in the study period using propensity score matching for several important parameters. Multi-variable logistic regression models were used to estimate the association between body mass index (BMI) and the risk of developing PJI. Interaction and stratified analyses were conducted according to age, sex, type of surgery, smoking status, alcohol use, diabetes, inflammatory arthritis, liver disease and renal disease.

FINDINGS

The multiple logistic analyses showed that obesity was associated with increased risk of PJI [odds ratio (OR) 2.48; 95% confidence interval (CI) 1.66-3.69]. When analysed as a continuous variable, BMI was also associated with increased risk of PJI (OR per 1 kg/m² increase in BMI 1.08; 95% CI 1.02-1.14). In the interaction analysis, patients who were obese and smoked had a higher OR of developing PJI than non-smokers who were obese (OR 3.54 vs 1.55, P-value for interaction=0.031). Similarly, the OR was much higher for patients with both obesity and inflammatory arthritis than for patients who were obese with no history of inflammatory arthritis (OR 3.9 vs 1.55, P-value for interaction=0.029). No other significant interactions were found in the association between obesity and PJI.

CONCLUSION

Obesity is an independent risk factor for the development of PJI in the Chinese Han population. Surgeons should be aware that obese patients who smoke or have inflammatory arthritis are at additional increased risk of PJI.

Tobacco Cessation in Oncology Care

Globally, tobacco use is a major modifiable risk factor and leading cause of many forms of cancer and cancer death. Tobacco use contributes to poorer prognosis in cancer care. This article reviews the current state of tobacco cessation treatment in oncology. Effective behavioral and pharmacological treatments exist for tobacco cessation, but are not being widely used in oncology treatment settings. Comprehensive tobacco treatment increases success with quitting smoking and can improve oncological and overall health outcomes. This article describes the components of a model treatment program, which includes automatic referrals for all current tobacco users and recent quitters, motivational interviewing during initial and follow-up contacts, combined behavioral and pharmacological interventions for cessation, and systematic follow-up phone calls for relapse prevention.

Perioperative and Modifiable Risk Factors for Periprosthetic Joint Infections (PJI) and Recommended Guidelines

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) remains a complication that is associated with high morbidity as well as high healthcare expenses. The purpose of this review is to examine patient and perioperative modifiable risk factors that can be altered to help improve rates of PJI.

RECENT FINDINGS

Evidence-based review of literature shows that improved control of post-operative glycemia, appropriate management of obesity, malnutrition, metabolic syndrome, preoperative anemia, and smoking cessation can help minimize risk of PJI. Additionally, use of Staphylococcus aureus screening, preoperative evaluation of vitamin D levels, screening for urinary tract infection, and examination of dental hygiene can help with improving rates of PJI; similarly, appropriate management of perioperative variables such as limiting operating room traffic, appropriate timing, and selection of prophylactic antibiotics and surgical site preparation can help to decrease rates of PJI. In summary, PJI is a morbid complication of total joint arthroplasty. Surgeons should be vigilant of modifiable risk factors that can be improved upon to help minimize the risk of PJI.

[Peri-operative management of smoking]

Smoking is a public health issue, especially during the perioperative period. Tobacco increases the risk of hospital mortality by 20% and major postoperative complications by 40%. Active smoking is associated with respiratory complications particularly bronchospasm and pneumonia, but also all surgical complications as scar infections, local thrombosis, suture release and delayed bone healing. The perioperative period is an opportunity to stop smoking. Smoking cessation should always be recommended, regardless of the surgery and the date of intervention. All health professionals, doctors, surgeons, anesthetists, but also nurses and physiotherapists, must inform smokers of the benefits of stopping smoking, offer them a dedicated support and a personalized follow-up. Tobacco consultation and the prescription of nicotine replacement increase the rate of smoking cessation. Stopping smoking reduces perioperative complications and is associated with health benefits that increase with time.

Pulmonary function in women: comparative analysis of conventional versus single-port laparoscopic cholecystectomy

OBJECTIVE

to evaluate the pulmonary function of women submitted to conventional and single-port laparoscopic cholecystectomy.

METHODS

forty women with symptomatic cholelithiasis, aged 18 to 70 years, participated in the study. We divided the patients into two groups: 21 patients underwent conventional laparoscopic cholecystectomy, and 19, single-port laparoscopic cholecystectomy. We assessed pulmonary function through forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), and the FEV1/FVC ratio, measured before and 24 hours after the procedure.

RESULTS

in both groups, FVC and FEV1 were lower in the postoperative period than those obtained in the preoperative period, with a greater reduction in the group undergoing conventional laparoscopic cholecystectomy. Regarding the FEV1/FVC (%) values, there was no statistically significant difference in any of the groups or times analyzed.

CONCLUSION

there was a greater decline in FVC and FEV1 in the postoperative group of patients submitted to conventional laparoscopic cholecystectomy.

Surgical Technical Evidence Review of Hip Fracture Surgery Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Enhanced recovery pathways (ERPs) have been shown to improve patient outcomes in a variety of contexts. This review summarizes the evidence and defines a protocol for perioperative care of patients with hip fracture and was conducted for the Agency for Healthcare Research and Quality safety program for improving surgical care and recovery.

Study Design:

Perioperative care was divided into components or “bins.” For each bin, a semisystematic review of the literature was conducted using MEDLINE with priority given to systematic reviews, meta-analyses, and randomized controlled trials. Observational studies were included when higher levels of evidence were not available. Existing guidelines for perioperative care were also incorporated. For convenience, the components of care that are under the auspices of anesthesia providers will be reported separately. Recommendations for an evidence-based protocol were synthesized based on review of this evidence.

Results:

Eleven bins were identified. Preoperative risk factor bins included nutrition, diabetes mellitus, tobacco use, and anemia. Perioperative management bins included thromboprophylaxis, timing of surgery, fluid management, drain placement, early mobilization, early alimentation, and discharge criteria/planning.

Conclusions:

This review provides the evidence basis for an ERP for perioperative care of patients with hip fracture.

Perceptions of Continued Smoking and Smoking Cessation Among Patients With Cancer

PURPOSE

Continued smoking after a cancer diagnosis leads to poorer treatment outcomes, survival, and quality of life. We evaluated the perceptions of the effects of continued smoking on quality of life, survival, and fatigue among patients with cancer after a cancer diagnosis and the effects of these perceptions on smoking cessation.

PATIENTS AND METHODS

Patients with cancer from all disease subsites from Princess Margaret Cancer Centre (Toronto, Ontario) were surveyed between April 2014 and May 2016 for sociodemographic variables, smoking history, and perceptions of continued smoking on quality of life, survival, and fatigue. Multivariable regression models evaluated the association between patients' perceptions and smoking cessation and the factors influencing patients' perceptions of smoking.

RESULTS

Among 1,121 patients, 277 (23%) were smoking cigarettes up to 1 year before diagnosis, and 54% subsequently quit; 23% had lung cancer, and 27% had head and neck cancers. The majority felt that continued smoking after a cancer diagnosis negatively affected quality of life (83%), survival (86%), and fatigue (82%). Current smokers during the peridiagnosis period were less likely to perceive that continued smoking was harmful when compared with ex-smokers and never-smokers ( P < .01). Among current smokers, perceiving that smoking negatively affected quality of life (adjusted odds ratio [aOR], 2.68 [95% CI, 1.26 to 5.72]; P = .011), survival (aOR, 5.00 [95% CI, 2.19 to 11.43]; P < .001), and fatigue (aOR, 3.57 [95% CI, 1.69 to 7.54]; P < .001) were each strongly associated with smoking cessation. Among all patients, those with a greater smoking history were less likely to believe that smoking was harmful in terms of quality of life (aOR, 0.98 [95% CI, 0.98 to 0.99]; P < .001), survival (aOR, 0.98 [95% CI, 0.98 to 0.99]; P < .001), and fatigue (aOR, 0.99 [95% CI, 0.98 to 0.99]; P < .001).

CONCLUSION

The perceptions of continued smoking after a cancer diagnosis among patients with cancer are strongly associated with smoking cessation. Counseling about the harms of continued smoking in patients with cancer, and in particular among those who have lower risk perceptions, should be considered when developing a smoking cessation program.

Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1)

In the face of escalating costs and variations in quality of care, bundled payment models for total joint arthroplasty procedures are becoming increasingly common, both through the Centers for Medicare & Medicaid Services and private payer organizations. The effective implementation of these payment models requires cooperation between multiple service providers to ensure economic viability without deterioration in care quality. This article introduces a stepwise model for the financial analysis of bundled contracts for use in negotiations between hospitals and private payer organizations.

Effect of a Smoking Cessation Program on Sexual Function Recovery Following Robotic Prostatectomy at Kaiser Permanente Southern California

INTRODUCTION

The association between cigarette smoking and erectile dysfunction has been well established. Studies demonstrate improvements in erectile rigidity and tumescence as a result of smoking cessation. Radical prostatectomy is also associated with worsening of erectile function secondary to damage to the neurovascular bundles. To our knowledge, no previous studies have examined the relationship between smoking cessation after prostate cancer diagnosis and its effect on sexual function following robotic prostatectomy. We sought to demonstrate the utility of a smoking cessation program among patients with prostate cancer who planned to undergo robotic prostatectomy at Kaiser Permanente Southern California.

METHODS

All patients who underwent robotic prostatectomy between March 2011 and April 2013 with known smoking status were included, and were followed-up through November 2014. All smokers were offered the smoking cessation program, which included wellness coaching, tobacco cessation classes, and pharmacotherapy. Patients completed the Expanded Prostate Cancer Index Composite-26 (EPIC-26) health-related quality-of-life (HR-QOL) survey at baseline and postoperatively at 1, 3, 6, 12, 18, and 24 months. There were 2 groups based on smoking status: Continued smoking vs quitting group. Patient's age, Charlson Comorbidity Score, body mass index, educational level, median household income, family history of prostate cancer, race/ethnicity, language, nerve-sparing status, and preoperative/postoperative clinicopathology and EPIC-26 HR-QOL scores were examined. A linear regression model was used to predict sexual function recovery.

RESULTS

A total of 139 patients identified as smokers underwent the smoking cessation program and completed the EPIC-26 surveys. Fifty-six patients quit smoking, whereas 83 remained smokers at last follow-up. All demographics and clinicopathology were matched between the 2 cohorts. Smoking cessation, along with bilateral nerve-sparing status, were the only 2 modifiable factors associated with improved sexual function after prostatectomy (6.57 points, p = 0.0226 and 8.97 points, p = 0.0485, respectively).

CONCLUSION

In the setting of robotic prostatectomy, perioperative smoking cessation is associated with a significant improvement in long-term sexual functional outcome when other factors are adjusted.

The effect of smoking on 30-day outcomes in elective hernia repair

BACKGROUND

Adverse postoperative outcomes related to smoking are well established, yet current smokers continue to be offered elective surgery in the US. It is unknown whether patients undergoing low-risk, elective procedures, who actively smoke experience increased risk of complications. We sought to determine the increased burden of complications following elective hernia repair procedures in patients identified as current smokers.

METHODS

We identified patients undergoing elective incisional, inguinal, umbilical, or ventral hernia repair from 2011 to 2014 using the American College of Surgeons National Surgical Quality Improvement Project (ACS NSQIP) database. Multivariable logistic regression analysis was used to examine the association between current smoking and 30-day postoperative outcomes, adjusting for demographics and comorbidities.

RESULTS

Of 220,629 patients who underwent elective hernia repair, 40,446 (18.3%) self-identified as current smokers within the past 12 months. Current smokers experienced an increased likelihood (Odds Ratio [95% Confidence interval]) of reoperation (OR 1.23 [95% CI 1.11-1.36]), readmission (OR 1.24 [95% CI 1.16-1.32]), and death (OR 1.53 [95% CI 1.06-2.22]). Furthermore, smokers experienced an increased risk of postoperative pulmonary, infectious, and wound complications, but there was no increased risk of requiring transfusion or of postoperative cardiac or thromboembolic events.

CONCLUSIONS

Current smokers were more likely to experience serious postoperative complications within 30 days. Given the volume of elective hernia surgery performed in the US, encouraging smoking cessation prior to offering elective repair could reduce postoperative complications, reoperation, readmission, and mortality.

Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery

Background:

Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Study Design:

This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format.

Results:

Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning.

Conclusion:

This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.

Proposal for a national triage system for the management of ventral hernias

Ventral hernia disease is becoming increasingly prevalent and complex. Subspecialisation for patients with challenging conditions requiring surgery has been shown to improve postoperative outcomes. Worldwide, there is an emergence of specialist hernia centres using new and innovative techniques to repair large and complicated ventral hernias. After a national meeting of hernia experts, we present an algorithm to be used as a national triage system for patients with ventral hernias, with the aim of ensuring that patients are operated on by the most appropriate surgeon. Evidence-based clinical risk factors and ventral hernia parameters are used for risk stratification and patient triage. We hope that this algorithm will guide future ventral hernia management in the UK.

Enhanced Recovery After Surgery for Radical Cystectomy

Even with advances in perioperative medical care, anesthetic management, and surgical techniques, radical cystectomy (RC) continues to be associated with a high morbidity rate as well as a prolonged length of hospital stay. In recent years, there has been great interest in identifying multimodal and interdisciplinary strategies that help accelerate postoperative convalescence by reducing variation in perioperative care of patients undergoing complex surgeries. Enhanced recovery after surgery (ERAS) attempts to evaluate and incorporate scientific evidence for modifying as many of the factors contributing to the morbidity of RC as possible, and optimize how patients are cared for before and after surgery. In this chapter, we review the preoperative, intraoperative and postoperative elements of using an ERAS protocol for RC.

Full-thickness skin graft vs. synthetic mesh in the repair of giant incisional hernia: a randomized controlled multicenter study

PURPOSE

Repair of large incisional hernias includes the implantation of a synthetic mesh, but this may lead to pain, stiffness, infection and enterocutaneous fistulae. Autologous full-thickness skin graft as on-lay reinforcement has been tested in eight high-risk patients in a proof-of-concept study, with satisfactory results. In this multicenter randomized study, the use of skin graft was compared to synthetic mesh in giant ventral hernia repair.

METHODS

Non-smoking patients with a ventral hernia > 10 cm wide were randomized to repair using an on-lay autologous full-thickness skin graft or a synthetic mesh. The primary endpoint was surgical site complications during the first 3 months. A secondary endpoint was patient comfort. Fifty-three patients were included. Clinical evaluation was performed at a 3-month follow-up appointment.

RESULTS

There were fewer patients in the skin graft group reporting discomfort: 3 (13%) vs. 12 (43%) (p = 0.016). Skin graft patients had less pain and a better general improvement. No difference was seen regarding seroma; 13 (54%) vs. 13 (46%), or subcutaneous wound infection; 5 (20%) vs. 7 (25%). One recurrence appeared in each group. Three patients in the skin graft group and two in the synthetic mesh group were admitted to the intensive care unit.

CONCLUSION

No difference was seen for the primary endpoint short-term surgical complication. Full-thickness skin graft appears to be a reliable material for ventral hernia repair producing no more complications than when using synthetic mesh. Patients repaired with a skin graft have less subjective abdominal wall symptoms.

Treatment Approach for Infection of Healed Fractures After Internal Fixation

OBJECTIVE

To review the efficacy of a treatment approach for patients with infection and colonized implants after open reduction and internal fixation of fractures.

DESIGN

Retrospective case series.

SETTING

Level one trauma center.

PATIENTS

Twenty patients were treated for wound infection with colonized implants after open reduction and internal fixation.

INTERVENTION

Surgical debridement, removal of implants, and a short postoperative oral antibiotic course.

MAIN OUTCOME MEASUREMENT

The course of patients after surgical debridement and removal of implants, including culture results, antibiotic administration, and presence of recurrent clinical infection and radiographic union.

RESULTS

Twenty patients had clinical presentations, including skin breakdown, serous drainage, purulent drainage and/or exposed implants, most commonly of the tibia (15 of 20). Mean time from index procedure to debridement with implant removal was 19.7 months. At the time of debridement and implant removal, 18 of 20 (90%) patients had a positive intraoperative culture (16 routine cultures and 2 broth cultures). The most common bacteria were Enterobacter cloacae (5/17) and methicillin-sensitive Staphylococcus aureus (4/17). All patients had soft tissue healing without signs of recurrent infection after mean follow up of 40 months after implant removal.

CONCLUSIONS

Surgical debridement with implant removal plus a short oral antibiotic course is effective to resolve wound infection with a colonized implant in the setting of healed fracture after internal fixation.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Enhancing Recovery After Total Knee Arthroplasty

There have been multiple successful efforts to improve and shorten the recovery period after elective total joint arthroplasty. The development of rapid recovery protocols through a multidisciplinary approach has occurred in recent years to improve patient satisfaction as well as outcomes. Bundled care payment programs and the practice of outpatient total joint arthroplasty have provided additional pressure and incentives for surgeons to provide high-quality care with low cost and complications. In this review, the evidence for modern practices are reviewed regarding patient selection and education, anesthetic techniques, perioperative pain management, intraoperative factors, blood management, and postoperative rehabilitation.

Impact of alcohol & smoking on the surgical management of gastrointestinal patients

Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.

STOP smoking and alcohol drinking before OPeration for bladder cancer (the STOP-OP study), perioperative smoking and alcohol cessation intervention in relation to radical cystectomy: study protocol for a randomised controlled trial

Background

To evaluate the effect of a smoking-, alcohol- or combined-cessation intervention starting shortly before surgery and lasting 6 weeks on overall complications after radical cystectomy. Secondary objectives are to examine the effect on types and grades of complications, smoking cessation and alcohol cessation, length of hospital stay, health-related quality of life and return to work or habitual level of activity up to 12 months postoperatively.

Methods/design

The study is a multi-institutional randomised clinical trial involving 110 patients with a risky alcohol intake and daily smoking who are scheduled for radical cystectomy. Patients will be randomised to the 6-week Gold Standard Programme (GSP) or treatment as usual (control). The GSP combines patient education and pharmacologic strategies. Smoking and alcohol intake is biochemically validated (blood, urine and breath tests) at the weekly meetings and at follow-up.

Discussion

Herein, we report the design of the STOP-OP study, objectives and accrual up-date. This study will provide new knowledge about how to prevent smoking and alcohol-related postoperative complications at the time of bladder cancer surgery. Till now 77 patients have been enrolled. Patient accrual is expected to be finalised before the end of 2017 and data will be published in 2018.

Trial registration

ClinicalTrials.gov, ID: NCT02188446. Registered on 28 May 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2065-6) contains supplementary material, which is available to authorized users.

Smoking Cessation Rates among Patients Undergoing Vascular Surgery in a Canadian Center

BACKGROUND

Smoking is the single most important modifiable risk factor for patients with vascular disease. The aim of this study was to determine the prevalence of smoking and cessation rates among patients undergoing vascular surgery in a Canadian center.

METHODS

As part of the Vascular Quality Initiative, a prospectively maintained database was used to identify the patients undergoing vascular surgery between 2010 and 2013. Smoking prevalence data were collated preprocedure, postprocedure, and at year follow-up after intervention at a median of 13 months (mean = 14.4 ± 7.8 months). Cessation rates at 13-month follow-up were assessed to determine any statistically significant univariate factors. These factors were then used to build a model through backwards logistic regression. Multicollinearity was tested by assessing both variance inflation factors and tolerance.

RESULTS

Overall, 624 patients had complete follow-up data. Of these, 209 (33.5%) were smokers presurgically. At 1-year follow-up, of those 209 patients who were smokers preoperatively, 87 (41.6%) had stopped smoking while 122 (58.4%) had not. Patients who were male and aged >70 years were more likely to be smokers preoperatively (P = 0.001 and P < 0.001, respectively). Cessation rates were increased in those aged >70 years (P = 0.005) and in those with chronic obstructive pulmonary disease (P = 0.016). Gender was also statistically associated, with cessation rates higher in females (P = 0.011).

CONCLUSIONS

More than one-third of patients who underwent surgery in a Canadian vascular center continue to smoke. Uniquely, we report a statistically significant association between gender and postoperative cessation rates.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review

OBJECTIVE

To achieve consensus on the best practices in the management of ventral hernias (VH).

BACKGROUND

Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence.

METHODS

A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy.

RESULTS

Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients.

CONCLUSIONS

Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

How Can Smoking Cessation Be Induced Before Surgery? A Systematic Review and Meta-Analysis of Behavior Change Techniques and Other Intervention Characteristics

Background: Smokers who continue to smoke up to the point of surgery are at increased risk of a range of complications during and following surgery.

Objective: To identify whether behavioral and/or pharmacological interventions increase the likelihood that smokers quit prior to elective surgery and which intervention components are associated with larger effects.

Design: Systematic review with meta-analysis.

Data sources: MEDLINE, Embase, and Embase Classic, CINAHL, CENTRAL.

Study selection: Studies testing the effect of smoking reduction interventions delivered at least 24 h before elective surgery were included.

Study appraisal and synthesis: Potential studies were independently screened by two people. Data relating to study characteristics and risk of bias were extracted. The effects of the interventions on pre-operative smoking abstinence were estimated using random effects meta-analyses. The association between specific intervention components (behavior change techniques; mode; duration; number of sessions; interventionist) and smoking cessation effect sizes were estimated using meta-regressions.

Results: Twenty-two studies comprising 2,992 smokers were included and 19 studies were meta-analyzed. Interventions increased the proportion of smokers who were abstinent or reduced smoking by surgery relative to control: g = 0.56, 95% CI 0.32–0.80, with rates nearly double in the intervention (46.2%) relative to the control (24.5%). Interventions that comprised more sessions, delivered face-to-face and by nurses, as well as specific behavior change techniques (providing information on consequence of smoking/cessation; providing information on withdrawal symptoms; goal setting; review of goals; regular monitoring by others; and giving options for additional or later support) were associated with larger effects.

Conclusion: Rates of smoking can be halved prior to surgery and a number of intervention characteristics can increase these effects. There was, however, some indication of publication bias meaning the benefits of such interventions may be smaller than estimated.

Registration: Prospero 2015: CRD42015024733

Financial benefit of a smoking cessation program prior to elective colorectal surgery

BACKGROUND

Cigarette smoking increases the risk of postoperative complications nearly 2-fold. Preoperative smoking cessation programs may reduce complications as well as overall postoperative costs. We aim to create an economic evaluation framework to estimate the potential value of preoperative smoking cessation programs for patients undergoing elective colorectal surgery.

METHODS

A decision-analytic model from the payer perspective was developed to integrate the costs and incidence of 90-day postoperative complications and readmissions for a cohort of patients undergoing elective colorectal surgery after a smoking cessation program versus usual care. Complication, readmission, and cost data were derived from a cohort of 534 current smokers and recent quitters undergoing elective colorectal resections in Washington State's Surgical Care and Outcomes Assessment Program linked to Washington State's Comprehensive Hospital Abstract Reporting System. Smoking cessation program efficacy was obtained from the literature. Sensitivity analyses were performed to account for uncertainty.

RESULTS

For a cohort of patients, the base case estimates imply that the total direct medical costs for patients who underwent a preoperative smoking cessation program were on average $304 (95% CI: $40-$571) lower per patient than those under usual care during the first 90 days after surgery. The model was most sensitive to the odds of recent quitters developing complications or requiring readmission, and smoking program efficacy.

CONCLUSIONS

A preoperative smoking cessation program is predicted to be cost-saving over the global postoperative period if the cost of the intervention is below $304 per patient. This framework allows the value of smoking cessation programs of variable cost and effectiveness to be determined.

Incidence and risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture: A systematic review and meta-analysis

BACKGROUND

This study aimed to quantitatively summarize the risk factors associated with surgical site infection after open reduction and internal fixation of tibial plateau fracture.

METHODS

Medline, Embase, CNKI, Wanfang database and Cochrane central database were searched for relevant original studies from database inception to October 2016. Eligible studies had to meet quality assessment criteria according to the Newcastle-Ottawa Scale, and had to evaluate the risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture. Stata 11.0 software was used for this meta-analysis.

RESULTS

Eight studies involving 2214 cases of tibial plateau fracture treated by open reduction and internal fixation and 219 cases of surgical site infection were included in this meta-analysis. The following parameters were identified as significant risk factors for surgical site infection after open reduction and internal fixation of tibial plateau fracture (p < 0.05): open fracture (OR 3.78; 95% CI 2.71-5.27), compartment syndrome (OR 3.53; 95% CI 2.13-5.86), operative time (OR 2.15; 95% CI 1.53-3.02), tobacco use (OR 2.13; 95% CI 1.13-3.99), and external fixation (OR 2.07; 95% CI 1.05-4.09). Other factors, including male sex, were not identified as risk factors for surgical site infection.

CONCLUSION

Patients with the abovementioned medical conditions are at risk of surgical site infection after open reduction and internal fixation of tibial plateau fracture. Surgeons should be cognizant of these risks and give relevant preoperative advice.

Posttraumatic Reconstruction of the Foot and Ankle in the Face of Active Infection

Posttraumatic infection of the foot and ankle is a challenging issue for orthopedic surgeons. Making the diagnosis often requires combining laboratory and radiologic testing, patient examination, and history. Patient comorbidities should be identified and optimized whenever possible. Treatment must combine effective antibiotic therapy with thorough debridement of the infected zone. Reconstruction often requires a 2-staged approach using antibiotic spacers and temporary external fixation, with the goal of obtaining a functional, pain-free limb that is free of infection.

Incidence and risks for surgical site infection after adult tibial plateau fractures treated by ORIF: a prospective multicentre study

Tibial plateau fractures are difficult to treat and more likely complicated by subsequent surgical site infection (SSI). There is limited information about its characteristics and related risk factors for SSI. This study was designed as a prospective and multicentre one to address this issue. From July to 15 November in 2014, 235 patients with tibial plateau fractures were treated by open reduction and internal fixation (ORIF) and followed up with complete data. Twelve patients (5·1%, 12/235) developed SSI, with 2·1% for deep SSI and 3·0% for superficial SSI. Most of them (10/12) occurred during the hospital stays. The median occurrence time was 6 days after operation (range, 2-26 days). We use univariate and multivariate logistic regression models to investigate the potential risk factors. In the univariate analysis, open fracture, prolonged preoperative stay, smoking habitus and preoperative abnormal neutrophil (NEUT) count were significant risk factors for SSI occurrence. However, in multivariate analysis, only open fracture (OR, 3·31; 95%, 1·06-1·84) and current smoking status (OR, 5·68; 95% CI, 1·56-20·66) remained significant. We recommend that smoking cessation programme is introduced at the time of admission to the hospital and elaborative evaluation of fracture severity and soft-tissue damage is performed with an aim of reducing the risk of post-operative SSI.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Impact of Smoking Cessation Counseling Prior to Total Joint Arthroplasty

Perioperative smoking has been linked to surgical complications including poor wound healing, infection, myocardial infarction, prolonged length of stay, need for mechanical ventilation, and death. This study evaluated the effectiveness of preoperative counseling on smoking cessation for patients undergoing elective total joint arthroplasty. Thirty smokers with hip or knee osteoarthritis seeking hip or knee replacement surgery were enrolled prospectively. Interventions included counseling, referrals to smoking cessation programs including the California Smokers' Helpline and the Fontana Tobacco Treatment Program, nicotine replacement therapy (NRT), or instructing patients quit through the "cold turkey" method of abstinence. Patients were scheduled for surgery if they demonstrated abstinence from smoking, confirmed via expired carbon monoxide (CO) breath testing. Short- and long-term smoking cessation rates were evaluated. Thirty patients were enrolled; 21 patients (70%) passed the CO test, whereas 9 patients (30%) failed or did not follow up with a CO test. Thirteen of 21 patients (62%) quit using the "cold turkey" method, 5 of 21 patients (24%) quit using NRT, and 3 of 21 patients (14%) quit using outpatient treatment programs. Eighteen of 21 patients (86%) who quit smoking underwent surgery, and 14 patients had surgery within 6 months of smoking abstinence. Nine of the 14 patients (64%) remained smoke-free 6 months postoperatively confirmed through telephone questionnaire. These results suggest that elective surgery offers a strong incentive for patients to quit smoking, and surgeons can play a role offering a teachable moment and motivating this potentially life-altering behavioral change. [Orthopedics. 2017; 40(2):e323-e328.].

Enhanced Recovery Pathways in Gynecology and Gynecologic Oncology

IMPORTANCE

Enhanced recovery programs (ERPs) are considered standard of care across a variety of surgical disciplines, but ERPs have not been widely adopted in gynecology.

OBJECTIVE

The aim of this study was to describe ERP principles and the role of ERPs in gynecology and gynecologic oncology.

EVIDENCE ACQUISITION

Comprehensive literature search was performed using MEDLINE, the Cochrane Collaboration Database, and PubMed.

RESULTS

Meta-analyses of a substantial number of randomized controlled trials have shown that implementation of ERP protocols is associated with decreased length of hospital stay, a decrease in rates of postoperative complication, decreased morbidity, and cost savings while preserving patient satisfaction and quality of life.

CONCLUSIONS AND RELEVANCE

High-quality evidence exists for improved outcomes among patients in ERPs. Enhanced recovery programs save resources and costs across the health care system. As quality metrics and bundled payments increase in health care, ERPs will have increasing prominence.