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Regan C, Transtrum MB, Jilakara B, Milbrandt TA, Larson AN. How Long Can You Delay? Curve Progression While Awaiting Vertebral Body Tethering Surgery. J Clin Med 2024; 13:2209. [PMID: 38673483 PMCID: PMC11050359 DOI: 10.3390/jcm13082209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 04/28/2024] Open
Abstract
Background: The implications of delaying surgical intervention for patients with adolescent idiopathic scoliosis (AIS) wishing to undergo vertebral body tethering (VBT) have not yet been explored. It is important to understand how these delays can impact surgical planning and patient outcomes. Methods: This was a retrospective review that analyzed all AIS patients treated between 2015 and 2021 at a single tertiary center. Time to surgery from initial surgical consultation and ultimate surgical plan were assessed. Patient characteristics, potential risk factors associated with increased curve progression, and reasons for delay were also analyzed. Results: 174 patients were evaluated and 95 were scheduled for VBT. Four patients later required a change to posterior spinal fusion (PSF) due to excessive curve progression. Patients requiring PSF were shown to have significantly longer delays than those who received VBT. Additionally, longer delays, younger age, greater curve progression, and lower skeletal maturity were correlated with significant curve progression (≥5 degrees). Conclusions: Surgical delays for AIS patients awaiting VBT may lead to significant curve progression and necessitate more invasive procedures. Patients with longer delays experienced an increased risk of needing PSF instead of VBT. Of those requiring PSF, the majority were due to insurance denials. Optimizing surgical timing and shared decision-making among patients, families, and healthcare providers are essential for achieving the best outcomes.
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Affiliation(s)
| | | | | | | | - A. Noelle Larson
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA; (C.R.); (M.B.T.); (B.J.); (T.A.M.)
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Forssten MP, Mohammad Ismail A, Ioannidis I, Ribeiro MAF, Cao Y, Sarani B, Mohseni S. Prioritizing patients for hip fracture surgery: the role of frailty and cardiac risk. Front Surg 2024; 11:1367457. [PMID: 38525320 PMCID: PMC10957751 DOI: 10.3389/fsurg.2024.1367457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction The number of patients with hip fractures continues to rise as the average age of the population increases. Optimizing outcomes in this cohort is predicated on timely operative repair. The aim of this study was to determine if patients with hip fractures who are frail or have a higher cardiac risk suffer from an increased risk of in-hospital mortality when surgery is postponed >24 h. Methods All patients registered in the 2013-2021 TQIP dataset who were ≥65 years old and underwent surgical fixation of an isolated hip fracture caused by a ground-level fall were included. Adjustment for confounding was performed using inverse probability weighting (IPW) while stratifying for frailty with the Orthopedic Frailty Score (OFS) and cardiac risk using the Revised Cardiac Risk Index (RCRI). The outcome was presented as the absolute risk difference in in-hospital mortality. Results A total of 254,400 patients were included. After IPW, all confounders were balanced. A delay in surgery was associated with an increased risk of in-hospital mortality across all strata, and, as the degree of frailty and cardiac risk increased, so too did the risk of mortality. In patients with OFS ≥4, delaying surgery >24 h was associated with a 2.33 percentage point increase in the absolute mortality rate (95% CI: 0.57-4.09, p = 0.010), resulting in a number needed to harm (NNH) of 43. Furthermore, the absolute risk of mortality increased by 4.65 percentage points in patients with RCRI ≥4 who had their surgery delayed >24 h (95% CI: 0.90-8.40, p = 0.015), resulting in a NNH of 22. For patients with OFS 0 and RCRI 0, the corresponding NNHs when delaying surgery >24 h were 345 and 333, respectively. Conclusion Delaying surgery beyond 24 h from admission increases the risk of mortality for all geriatric hip fracture patients. The magnitude of the negative impact increases with the patient's level of cardiac risk and frailty. Operative intervention should not be delayed based on frailty or cardiac risk.
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Affiliation(s)
- Maximilian Peter Forssten
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ahmad Mohammad Ismail
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Ioannis Ioannidis
- Department of Orthopedic Surgery, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
- School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Marcelo A. F. Ribeiro
- Pontifical Catholic University of São Paulo, São Paulo, Brazil
- Khalifa University and Gulf Medical University, Abu Dhabi, United Arab Emirates
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - Yang Cao
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Orebro University, Orebro, Sweden
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery, George Washington University School of Medicine & Health Sciences, Washington, DC, United States
| | - Shahin Mohseni
- School of Medical Sciences, Orebro University, Orebro, Sweden
- Department of Surgery, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
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Meyers N, Giron SE, Bush RA, Burkard JF. Patient-specific Predictors of Surgical Delay in a Large Tertiary-care Hospital Operating Room. J Perianesth Nurs 2024; 39:116-121. [PMID: 37831043 DOI: 10.1016/j.jopan.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 05/31/2023] [Accepted: 07/19/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE The purpose of this study was to describe patient-specific factors predictive of surgical delay in elective surgical cases. DESIGN Retrospective cohort study. METHODS Data were extracted retrospectively from the electronic health record of 32,818 patients who underwent surgery at a large academic hospital in Los Angeles between May 2012 and April 2017. Following bivariate analysis of patient-specific factors and surgical delay, statistically significant predictors were entered into a logistic regression model to determine the most significant predictors of surgical delay. FINDINGS Predictors of delay included having monitored anesthesia care (odds ratio [OR], 1.28; 95% confidence intervals [CI], 1.20-1.36), American Society of Anesthesiologist class 3 or above (OR, 1.21; 95% CI, 1.15-1.28), African American race (OR, 1.25; 95% CI, 1.12-1.39), renal failure (OR, 1.20; 95% CI, 1.09-1.32), steroid medication (OR, 1.13; 95% CI, 1.04-1.23) and Medicaid (OR,1.18; 95%CI, 1.09-1.30) or medicare insurance (OR, 1.14; 95% CI, 1.07-1.21). Six surgical specialties also increased the odds of delay. Obesity and cardiovascular anesthesia decreased the odds of delay. CONCLUSIONS Certain patient-specific factors including type of insurance, health status, and race were associated with surgical delay. Whereas monitored anesthesia care anesthesia was predictive of a delay, cardiovascular anesthesia reduced the odds of delay. Additionally, obese patients were less likely to experience a delay. While the electronic health record provided a large amount of detailed information, barriers existed to accessing meaningful data.
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Affiliation(s)
- Natalie Meyers
- Program of Nurse Anesthesia, University of Southern California, Los Angeles, CA.
| | - Sarah E Giron
- Kaiser Permanente School of Anesthesia, Pasadena, CA
| | - Ruth A Bush
- Hahn School of Nursing and Health Science, University of San Diego, San Deigo, CA
| | - Joseph F Burkard
- Hahn School of Nursing and Health Science, University of San Diego, San Deigo, CA
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Izawa Y, Murakami H, Shirakawa T, Futamura K, Hasegawa M, Tsuchida Y. Surgical delay in reverse sural artery flap prevents congestion of the flap: a case report of the stepwise delay method. Case Reports Plast Surg Hand Surg 2023; 10:2225610. [PMID: 37351524 PMCID: PMC10283432 DOI: 10.1080/23320885.2023.2225610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Abstract
We performed reverse sural artery flap (RSAF) with the stepwise delay method, cutting the vascular pedicle step by step, as the patient had a high risk of flap necrosis. Surgical delay in RSAF is anticipated to prevent not only flap cyanosis but also flap congestion.
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Affiliation(s)
- Yuta Izawa
- Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroko Murakami
- Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Tetsuya Shirakawa
- Department of Orthopedic Trauma Center, Sapporo Higashi Tokushukai Hospital, Sapporo, Hokkaido, Japan
| | - Kentaro Futamura
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Masayuki Hasegawa
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Yoshihiko Tsuchida
- Department of Trauma Center, Shonan Kamakura General Hospital, Kanagawa, Japan
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Garala P, Ahluwalia H. The impact of COVID-19 on the progression and management of periocular basal cell carcinomas. Orbit 2023; 42:138-141. [PMID: 35298344 DOI: 10.1080/01676830.2022.2043913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To identify whether the delay caused by COVID-19 had an impact on the peroperative size of lesions and the choice of reconstruction performed in patients with periocular basal cell carcinomas (BCCs). METHODS We undertook a retrospective study looking at whether the delay caused by COVID-19 had an impact on the lesion size at the time of surgery, and consequently, on the choice of surgical repair. Results were compared to an equivalent time period a year prior to the onset of COVID-19. Elective surgery was stepped down at our hospital between March and June 2020. We collected data on patients that underwent BCC excisions between July 2020 and April 2021 and for an equivalent time period from 2019 to 2020. Measurements at listing were compared with those preoperatively obtained and from histological specimen. RESULTS Analysis using the paired T-test yielded a p-value 0.005 for the growth of the lesion between listing and surgery after the onset of the pandemic, while pre-COVID the p-value was 0.04. Most patients were able to undergo the same procedure as planned for despite the delay and statistically significant growth while awaiting surgery. CONCLUSION Literature suggests that BCC operations can be safely delayed up to 3 months. Our longest wait post-COVID was 12 months with a mean wait of 5 months. Only two patients in this group had a more invasive surgery than planned. We conclude that the delay caused by the pandemic, even beyond 3 months, had a minimal impact on the surgical plan and outcomes for patients with BCCs.
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Affiliation(s)
- Pavitra Garala
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire, United Kingdom
| | - Harpreet Ahluwalia
- Department of Ophthalmology, University Hospitals Coventry and Warwickshire, United Kingdom
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Sanko C, Cox R, Hadley C, Gilmore G, Wood C, Getz C, Namdari S, Davis D. The impact of elective surgery restrictions during the COVID-19 (coronavirus disease 2019) pandemic on shoulder and elbow surgery: patient perceptions. J Shoulder Elbow Surg 2023; 32:662-670. [PMID: 36435483 PMCID: PMC9682864 DOI: 10.1016/j.jse.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND In late 2019 and early 2020, a novel coronavirus, COVID-19 (coronavirus disease 2019), spread across the world, creating a global pandemic. In the state of Pennsylvania, non-emergent, elective operations were temporarily delayed from proceeding with the normal standard of care. The primary purpose of this study was to determine the proportion of patients who required prescription pain medication during the surgical delay. Secondarily, we sought to determine the proportion of patients who perceived their surgical procedure as non-elective and to evaluate how symptoms were managed during the delay. MATERIALS AND METHODS A single institutional database was used to retrospectively identify all shoulder and elbow surgical procedures scheduled between March 13 and May 6, 2020. Charts were manually reviewed. Patients who underwent non-shoulder and elbow-related procedures and patients treated by surgeons outside of Pennsylvania were excluded. Patients whose surgical procedures were postponed or canceled were administered a survey evaluating how symptoms were managed and perceptions regarding the delay. Preoperative functional scores were collected. Statistical analysis was performed to determine associations between procedure status, preoperative functional scores, perception of surgery, and requirement for prescription pain medication. RESULTS A total of 338 patients were scheduled to undergo shoulder and elbow surgery in our practice in Pennsylvania. Surgery was performed as initially scheduled in 89 of these patients (26.3%), whereas surgery was postponed in 179 (71.9%) and canceled in 70 (28.1%). The average delay in surgery was 86.7 days (range, 13-299 days). Responses to the survey were received from 176 patients (70.7%) in whom surgery was postponed or canceled. During the delay, 39 patients (22.2%) required prescription pain medication. The surgical procedure was considered elective in nature by 73 patients (41%). One hundred thirty-seven patients (78%) would have moved forward with surgery if performed safely under appropriate medical guidelines. Lower preoperative American Shoulder and Elbow Surgeons scores (r = -0.36, P < .001) and Single Assessment Numeric Evaluation scores (r = -0.26, P = .016) and higher preoperative visual analog scale scores (r = 0.28, P = .009) were correlated with requiring prescription pain medication. Higher preoperative American Shoulder and Elbow Surgeons scores were positively correlated with perception of surgery as elective (r = 0.4, P < .001). CONCLUSION Patients undergoing elective shoulder and elbow surgical procedures during the COVID-19 (coronavirus disease 2019) pandemic experienced a delay of nearly 3 months on average. Fewer than half of patients perceived their surgical procedures as elective procedures. Nearly one-quarter of patients surveyed required extra prescription pain medicine during the delay. This study elucidates the fact that although orthopedic shoulder and elbow surgery is generally considered "elective," it is more important to a majority of patients. These findings may also be applicable to future potential mandated surgical care delays by other third-party organizations.
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Affiliation(s)
- Cassandra Sanko
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Ryan Cox
- Department of Orthopaedic Surgery, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Christopher Hadley
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Griffin Gilmore
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Chelsey Wood
- Sidney Kimmel Medical College, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Charles Getz
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Surena Namdari
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA
| | - Daniel Davis
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospitals, Philadelphia, PA, USA.
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Quevedo-Fernandez E, Gonzalez-Urquijo M, Hinojosa-Gonzalez DE, Morales-Flores LF, Morales-Morales CA, Zambrano-Lara M, Guajardo-Nieto D, Rodarte-Shade M. Analysis of deferral times in patients diagnosed with acute appendicitis. Asian J Surg 2023; 46:1187-1192. [PMID: 36041893 DOI: 10.1016/j.asjsur.2022.08.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 07/22/2022] [Accepted: 08/16/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION There are still controversies regarding the time of surgical management for acute appendicitis (AA). The main objective of this study was to recognize the surgical deferral time in patients with acute appendicitis and its relationship with the severity of presentation. MATERIALS AND METHODS We performed a retrospective review of prospectively collected data of all patients with acute appendicitis undergoing appendectomy from August 2018 to August 2020 in an academic, public hospital. Elapsed time from arrival to the emergency room to skin incision was determined. Patients were divided into three groups based on the elapsed time: less than 6 h, between 6 and 12 h, and more than 12 h. RESULTS A total of 782 patients were included. Of them, 443 (56.6%) patients had a surgical deferral time of less than 6 h, 238 (30.4%) patients between 6 and 12 h, and 101 (13%) patients of more than 12 h. Patients with more than 12 h of surgical deferral time had a more complicated clinical presentation (P = 0.013), a higher frequency of abscess formation (P = 0.022), higher requirement for the use of surgical drainage (P = 0.018), and longer length of hospital stay (P = <0.001). CONCLUSION Surgical deferral >12 h was associated with a higher incidence of complicated appendicitis, intra-abdominal abscesses, and overall hospital stay. However, in the multivariate analysis, only total evolution time, from the first symptom to surgery, was a significant independent predictor of complicated appendicitis.
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Affiliation(s)
- Enrique Quevedo-Fernandez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mauricio Gonzalez-Urquijo
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - David E Hinojosa-Gonzalez
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Luis Fernando Morales-Flores
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Carlos Antonio Morales-Morales
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Zambrano-Lara
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Diego Guajardo-Nieto
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
| | - Mario Rodarte-Shade
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Dr. Ignacio Morones Prieto O 3000, Monterrey, Nuevo León, 64710, Mexico.
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Sorey W, Hagen MS, Mand S, Sliepka J, Chin K, Schmale GA, Kweon C, Gee AO, Saper MG. Effect of Delayed Anterior Cruciate Ligament Reconstruction on Repair of Concomitant Medial Meniscus Tears in Young Athletes. Am J Sports Med 2023; 51:398-403. [PMID: 36533946 DOI: 10.1177/03635465221142325] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Delayed anterior cruciate ligament (ACL) reconstruction (ACLR) is associated with an increased risk of meniscal injury. Limited data are available regarding the relationship between surgical delay and meniscal repairability in the setting of ACLR in young patients. PURPOSE To determine whether time from ACL injury to primary ACLR was associated with the incidence of medial and/or lateral meniscal repair in young athletes who underwent meniscal treatment at the time of ACLR. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Records were retrospectively reviewed for patients aged 13 to 25 years who underwent primary ACLR between January 2017 and June 2020 by surgeons from a single academic orthopaedic surgery department. Demographic data were collected, and operative reports were reviewed to document all concomitant pathologies and procedures. Univariable and multivariable logistic regression analyses were used to determine factors associated with meniscal repair, including time elapsed from ACL injury to surgery. RESULTS Concomitant meniscal tears were identified and treated in 243 of 427 patients; their mean age was 17.9 ± 3.3 years, and approximately half (47.7%) of patients were female. There were 144 (59.3%) medial tears treated and 164 (67.5%) lateral tears treated; 65 (26.7%) patients had both medial and lateral tears treated. Median time from ACL injury to ACLR was 2.4 months (interquartile range, 1.4-4.7 months). Adjusted univariate analysis showed a statistically significant correlation between medial meniscal repair and time to surgery, with a 7% decreased incidence of medial meniscal repair per month elapsed between injury and surgery (odds ratio, 0.93 per month; 95% CI, 0.89-0.98; P = .006). No similar relationship was found between lateral meniscal repair and time to surgery (odds ratio, 1.02; 95% CI, 0.99-1.06; P = .24). CONCLUSION In the setting of concomitant ACL and meniscal injuries, surgical delay decreased the incidence of medial meniscal repair in young athletes by 7% per month from time of injury.
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Affiliation(s)
- Woody Sorey
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Mia S Hagen
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Simran Mand
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Joey Sliepka
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Kenneth Chin
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Gregory A Schmale
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Christopher Kweon
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Albert O Gee
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
| | - Michael G Saper
- Department of Orthopedics and Sports Medicine, University of Washington, Seattle, Washington, USA
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Kavak M, Oğuz S, Akkoyun Z, İnan U. Predictive factors associated with thirty-day mortality in geriatric patients with hip fractures. Acta Orthop Traumatol Turc 2022; 56:240-244. [PMID: 35968615 PMCID: PMC9612673 DOI: 10.5152/j.aott.2022.21407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study aimed to determine the predictive factors affecting the 30-day mortality in geriatric hip fractures, investigate the effect of the timing of surgery, and thus determine the optimum cut-off time in delaying the surgery. METHODS A total of 596 patients(205 men, 391 women; mean age = 78.3 years) were included in this retrospective study. All possible predictive factors encountered in the literature review, including age, sex, fracture type, comorbidities, American Society of Anesthesiologists (ASA) score, surgical delay time, anaesthesia type, surgery type, need for erythrocyte replacement, postoperative complications, and the need for postoperative intensive care were analyzed. The predictive factors that were found to be significant as a result of the univariate analysis were included in the multivariate logistic regression analysis. RESULTS The reason for surgery was an extracapsular fracture in 359 patients (60.2%) and an intracapsular fracture in 237 (39.8%). Arthroplasty was performed in 256 patients (43%), while proximal femoral nails were used in 251 (42.1%), dynamic hips screws in 68 (11.4%), and cannulated screws in 21 (3.5%). 523 (87.8%) of the patients had an ASA score of 1 or 2, and 73 (12.2%) had an ASA score of 3 or 4. General anaesthesia was performed on 35.2% of the patients, while regional anaesthesia was administered to 64.8%. Major complications developed in 42 patients (7%), while minor complications were observed in 143 (24%). The mean surgical delay time was 3.21 days (1-9 days). The ASA score (P <0.001, OR: 56.83, CI: 5.26-2.820), anesthesia type (P = 0.036, OR: 3.225, CI: 0.079-2.264), surgical delay time (P <0.001, OR: 2.006, CI: 1.02-0.372) and major complication (P = 0.002, OR: 6.41, CI: 0.661-3.053) were determined to be predictive factors of 30-day mortality. CONCLUSION This study found the median surgical delay time as three days in surviving patients and five days in deceased ones. Thus, a 3-day surgical delay may be acceptable and sufficient for medical optimization and the consensus of the multidisciplinary team. LEVEL OF EVIDENCE Level IV, Therapeutic Study.
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Hansen JB, Humble CAS, Møller AM, Vester-Andersen M. The prognostic value of surgical delay in patients undergoing major emergency abdominal surgery: a systematic review and meta-analysis. Scand J Gastroenterol 2022; 57:534-544. [PMID: 35019790 DOI: 10.1080/00365521.2021.2024250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Mortality following major emergency abdominal surgery is high. Surgical delay is regarded as an important modifiable prognostic factor. Current care-bundles aim at reducing surgical delay, most often using a six-hour cut-off. We aimed to investigate the evidence supporting the in-hospital delay cutoffs currently used. METHODS MEDLINE, EMBASE and the Cochrane Library were searched. We included studies assessing in-hospital surgical delay in major emergency abdominal surgery patients. Studies were only included if they performed adjusted analysis. Surgical delay beyond six hours was the primary cutfrom interest. The primary outcome was mortality at longest follow-up. Meta-analyses were conducted if possible. RESULTS Eleven observational studies were included with 16,772 participants. Two studies evaluated delay in unselected major emergency abdominal surgery patients. Three studies applied a six-hour cutoff, but only a study on acute mesenteric ischemia showed an association between delay and mortality. Meta-analysis showed no association with mortality at this cutoff. An association was seen between hourly delay and mortality risk estimate, 1.02 (95% confidence interval [CI], 1.00 - 1.03), and on subgroup analysis of hourly delay in perforated peptic ulcer patients, risk estimate, 1.02 (95% CI, 1.0 - 1.03). All risk estimates had a very low Grading of Recommendations Assessment, Development, and Evaluation score. CONCLUSION Little evidence supports a six-hour cutoff in unselected major emergency abdominal surgical patients. We found an association between hourly delay and increased mortality; however, evidence supporting this was primarily in patients undergoing surgery for perforated peptic ulcer. This review is limited by the quality of the individual studies.
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Affiliation(s)
- Jannick Brander Hansen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Caroline Anna Sofia Humble
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark.,Centre of Anaesthesiological Research, Department of Anaesthesiology, Zealand University Hospital, Køge, Denmark
| | - Ann Merete Møller
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
| | - Morten Vester-Andersen
- Herlev Anaesthesia Critical and Emergency Care Science Unit (ACES), Department of Anaesthesiology, Copenhagen University Hospital Herlev-Gentofte, Copenhagen, Denmark
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Wade SM, Fredericks DR, Elsenbeck MJ, Morrissey PB, Sebastian AS, Kaye ID, Butler JS, Wagner SC. The Incidence, Risk Factors, and Complications Associated With Surgical Delay in Multilevel Fusion for Adult Spinal Deformity. Global Spine J 2022; 12:441-446. [PMID: 32975455 PMCID: PMC9121150 DOI: 10.1177/2192568220954395] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective database review. OBJECTIVES The incidence and risk factors for surgical delay of multilevel spine fusion for adult spinal deformity (ASD), and the complications corresponding therewith, remain unknown. The objectives of this study are to assess the incidence and risk factors for unexpected delay of elective multilevel spinal fusions on the date of surgery as well as the postoperative complications associated with these delays. METHODS We conducted a retrospective review of the ACS-NSQIP database on patients undergoing elective spinal instrumentation of greater than 7 levels for ASD between the years 2005 and 2015. Preoperative risk factors for delay and postoperative complications were compared between the cohorts of patients with and without surgical delays. RESULTS Multivariate analysis of 1570 (15.6%) patients identified advanced age, male sex, American Society of Anesthesiologists (ASA) Class 4, and history of smoking as independent risk factors for delay. Patients experiencing surgical delay demonstrated longer operative times, increased intraoperative bleeding, longer hospitalizations, and significantly higher rates of postoperative complications. Patients experiencing delay demonstrated an almost 7-fold increase in mortality rate (3.4% vs 0.5%, P < .001). CONCLUSIONS Delays in elective surgical care for spinal deformity are negatively related to patient outcomes. Advanced age, male sex, increased ASA class, and a history of smoking cigarettes place patients at risk for surgical delay of multilevel spinal fusion. Patients experiencing surgical delay are at higher risk for postoperative complications, including a 7-fold increase in mortality. These findings suggest that ASD surgery should be postponed in patients experiencing a delay, until modifiable risk factors can be medically optimized, and perhaps postponed indefinitely in those with nonmodifiable risk factors.
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Affiliation(s)
- Sean M. Wade
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA,Sean M. Wade, Department of Orthopaedic Surgery, Walter Reed National Military Medical Center, America Building, 2nd Floor, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
| | - Donald R. Fredericks
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Michael J. Elsenbeck
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Patrick B. Morrissey
- Naval Medical Center San Diego, San Diego, CA, USA,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - I. David Kaye
- Rothman Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Joseph S. Butler
- Mater Misericordiae University Hospital, Mater Private Hospital, Dublin, Ireland
| | - Scott C. Wagner
- Uniformed Services University—Walter Reed National Military Medical Center, Bethesda, MD, USA,Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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12
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The impact of surgical delay on resectability of colorectal cancer: An international prospective cohort study. Colorectal Dis 2022; 24:708-726. [PMID: 35286766 PMCID: PMC9322431 DOI: 10.1111/codi.16117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 02/09/2022] [Accepted: 03/06/2022] [Indexed: 12/12/2022]
Abstract
AIM The SARS-CoV-2 pandemic has provided a unique opportunity to explore the impact of surgical delays on cancer resectability. This study aimed to compare resectability for colorectal cancer patients undergoing delayed versus non-delayed surgery. METHODS This was an international prospective cohort study of consecutive colorectal cancer patients with a decision for curative surgery (January-April 2020). Surgical delay was defined as an operation taking place more than 4 weeks after treatment decision, in a patient who did not receive neoadjuvant therapy. A subgroup analysis explored the effects of delay in elective patients only. The impact of longer delays was explored in a sensitivity analysis. The primary outcome was complete resection, defined as curative resection with an R0 margin. RESULTS Overall, 5453 patients from 304 hospitals in 47 countries were included, of whom 6.6% (358/5453) did not receive their planned operation. Of the 4304 operated patients without neoadjuvant therapy, 40.5% (1744/4304) were delayed beyond 4 weeks. Delayed patients were more likely to be older, men, more comorbid, have higher body mass index and have rectal cancer and early stage disease. Delayed patients had higher unadjusted rates of complete resection (93.7% vs. 91.9%, P = 0.032) and lower rates of emergency surgery (4.5% vs. 22.5%, P < 0.001). After adjustment, delay was not associated with a lower rate of complete resection (OR 1.18, 95% CI 0.90-1.55, P = 0.224), which was consistent in elective patients only (OR 0.94, 95% CI 0.69-1.27, P = 0.672). Longer delays were not associated with poorer outcomes. CONCLUSION One in 15 colorectal cancer patients did not receive their planned operation during the first wave of COVID-19. Surgical delay did not appear to compromise resectability, raising the hypothesis that any reduction in long-term survival attributable to delays is likely to be due to micro-metastatic disease.
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13
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Wu ZJ, Ibrahim MM, Sergesketter AR, Schweller RM, Phillips BT, Klitzman B. The Influence of Topical Vasodilator-Induced Pharmacologic Delay on Cutaneous Flap Viability and Vascular Remodeling. Plast Reconstr Surg 2022; 149:629-37. [PMID: 35041631 DOI: 10.1097/PRS.0000000000008829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Surgical delay is a well-described technique to improve survival of random and pedicled cutaneous flaps. The aim of this study was to test the topical agents minoxidil and iloprost as agents of pharmacologic delay to induce vascular remodeling and decrease overall flap necrosis as an alternative to surgical delay. METHODS Seven groups were studied (n = 8 in each group), including the following: vehicle, iloprost, or minoxidil before treatment only; vehicle, iloprost, or minoxidil before and after treatment; and a standard surgical delay group as a positive control. Surgical flaps (caudally based modified McFarlane myocutaneous skin flaps) were elevated after 14 days of pretreatment, reinset isotopically, and observed at various time points until postoperative day 7. Gross viability, histology, Doppler blood flow, perfusion imaging, tissue oxygenation measurement, and vascular casting were performed for analysis. RESULTS Pharmacologic delay with preoperative application of topical minoxidil or iloprost was found to have comparable flap viability when compared to surgical delay. Significantly increased viability in all treatment groups was observed when compared with vehicle. Continued postoperative treatment with topical agents had no effect on flap viability. The mechanism of improved flap viability was inducible increases in flap blood volume and perfusion rather than the acute vasodilatory effects of the topical agents or decreased flap hypoxia. CONCLUSIONS Preoperative topical application of the vasodilators minoxidil or iloprost improved flap viability comparably to surgical delay. Noninvasive pharmacologic delay may reduce postoperative complications without the need for an additional operation. CLINICAL RELEVANCE STATEMENT Preoperative use of topical vasodilators may lead to improved flap viability without the need for a surgical delay procedure. This study may inform future clinical trials examining utility of preoperative topical vasodilators in flap surgery.
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14
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Lee J, Forrester VJ, Novicoff WM, Guffey DJ, Russell MA. Surgical delays of less than 1 year in Mohs surgery associated with tumor growth in moderately- and poorly-differentiated squamous cell carcinomas but not lower-grade squamous cell carcinomas or basal cell carcinomas: A retrospective analysis. J Am Acad Dermatol 2021; 86:131-139. [PMID: 34499990 DOI: 10.1016/j.jaad.2021.08.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Evidence is controversial and limited concerning whether surgical delays are associated with tumor growth for cutaneous squamous cell carcinomas (SCCs) and basal cell carcinomas. OBJECTIVE Identify tumor subpopulations that may demonstrate an association between tumor growth and surgical delay. METHODS We retrospectively analyzed 299 SCCs and 802 basal cell carcinomas treated with Mohs surgery at a single institution. Time interval from biopsy to surgery represented surgical delay. Change in major diameter (ΔMD) from size at biopsy to postoperative defect represented tumor growth. Independent predictors of ΔMD were identified by multivariate analysis. Linear regression was then utilized to assess for whether the ΔMD from these independent predictors trended with surgical delay. RESULTS Surgical delays ranged from 0 to 331 days. Among SCCs, histologic subtype and prior treatment were identified as independent predictors of ΔMD. Significant associations between ΔMD and surgical delay were found for poorly- and moderately-differentiated SCCs, demonstrating growth rates of 0.28 cm and 0.24 cm per month of delay, respectively. The ΔMD for SCCs with prior treatment and basal cell carcinoma subgroups did not vary with surgical delay. LIMITATIONS Retrospective design, single center. CONCLUSION Surgical delays of less than a year were associated with tumor growth for higher-grade SCCs, with effect sizes bearing potential for clinical significance.
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Affiliation(s)
- Jack Lee
- Department of Dermatology, University of Virginia Health System, Charlottesville, Virginia.
| | - Vernon J Forrester
- Department of Dermatology, University of Virginia Health System, Charlottesville, Virginia
| | - Wendy M Novicoff
- Department of Orthopedic Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Darren J Guffey
- Department of Dermatology, University of Virginia Health System, Charlottesville, Virginia
| | - Mark A Russell
- Department of Dermatology, University of Virginia Health System, Charlottesville, Virginia
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15
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Meyers N, Giron SE, Burkard JF, Bush RA. Preventing Surgical Delay and Cancellation with Patient-Centered Interventions. J Perianesth Nurs 2021; 36:334-8. [PMID: 33714715 DOI: 10.1016/j.jopan.2020.10.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 11/23/2022]
Abstract
Delay and cancellation can significantly impact cost and outcomes among surgical patients. While the causes of delay and cancellation are not fully enumerated, possible reasons include delivery-related causes such as facility, equipment, and provider availability as well as patient-related issues such as readiness and health status. Despite limited research explaining patient-related causes, there are many studies that evaluate patient-centered interventions to decrease delay and cancellation. This article highlights patient-centered interventions including preoperative clinics, preoperative screening, and focused education that have been shown to reduce delay and cancellation. This information provides perianesthesia nurses and advanced practice nurses ideas to maximize their roles in improving efficiency by prevention of delay and cancellation. This article should also stimulate additional research to help better understand the causes and the role of the nurse in the implementation of evidence-based practice projects that use patient-centered interventions.
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16
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Law GW, Padki A, Tay KS, Howe TS, Koh JSB, Mak MS, Mohan PC, Chan LP, Png MA. Computed tomography-based diagnosis of occult fragility hip fractures offer shorter waiting times with no inadvertent missed diagnosis. J Orthop Surg (Hong Kong) 2021; 28:2309499020932082. [PMID: 32546057 DOI: 10.1177/2309499020932082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE Surgical delay due to the wait for advanced cross-sectional imaging in occult fragility hip fracture management is not well studied. Our study aims to investigate computed tomography (CT) as an alternative to the gold standard magnetic resonance imaging (MRI) in occult hip fracture workup to decrease surgical delay. METHODS We conducted a retrospective review of all CTs and MRIs performed between 2015 and 2017 for patients with clinically suspected fragility hip fractures and negative plain radiographs to investigate surgical delay resulting from the wait for advanced imaging and representations due to missed fractures. RESULTS A total of 243 scans (42 CTs and 201 MRIs) were performed for occult hip fracture workup over the study timeframe, of which 49 patients (20%) had occult hip fractures [CT: 6 (14%), MRI: 43 (21%), p = 0.296)]. There were no readmissions for fracture in the 12 months following a negative scan. The CT group had shorter waiting times (CT: 29 ± 24 h, MRI: 44 ± 32 h, p = 0.004) without significantly reducing surgical delay (CT: 82 ± 36 h, MRI: 128 ± 58 h, p = 0.196). The MRI group had a higher number of patients with a cancer history (p = 0.036), reflective of the practice for workup of possible metastases as a secondary intention. CONCLUSION Advanced cross-sectional imaging wait times in occult hip fracture workup contribute significantly to surgical delay. Modern CT techniques are not inferior to MRI in detecting occult fractures and may be a suitable alternative in the absence of a cancer history if MRI cannot be obtained in a timely fashion or is contraindicated. Clinicians should utilize the more readily available imaging modality to reduce surgical delay.
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Affiliation(s)
- Gin Way Law
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Akshay Padki
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Kae Sian Tay
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Tet Sen Howe
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | | | - May San Mak
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - P Chandra Mohan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Lai Peng Chan
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
| | - Meng Ai Png
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore
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17
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Fligor SC, Tsikis ST, Wang S, Ore AS, Allar BG, Whitlock AE, Calvillo-Ortiz R, Arndt K, Callery MP, Gangadharan SP. Time to surgery in thoracic cancers and prioritization during COVID-19: a systematic review. J Thorac Dis 2020; 12:6640-6654. [PMID: 33282365 PMCID: PMC7711379 DOI: 10.21037/jtd-20-2400] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronavirus disease 2019 (COVID-19) has overwhelmed hospital resources worldwide, requiring widespread cancellation of non-emergency operations, including lung and esophageal cancer operations. In the United States, while hospitals begin to increase surgical volume and tackle the backlog of cases, the specter of a “second wave,” with a potential vaccine months to years away, highlights the ongoing need to triage cases based upon the risk of surgical delay. We synthesize the available literature on time to surgery and its impact on outcomes along with a critical appraisal of the released triage guidelines in the United States. Methods We performed a systematic literature review using PubMed according to preferred reporting items for systematic reviews and meta-analyses guidelines evaluating relevant literature from the past 15 years. Results Out of 679 screened abstracts, 12 studies investigating time to surgery in lung cancer were included. In stage I–II lung cancer, delayed resection beyond 6 to 8 weeks is consistently associated with lower survival. No identified evidence justifies a 2 cm cutoff for immediate versus delayed surgery. For stage IIIa lung cancer, time to surgery greater than 6 weeks after neoadjuvant therapy is similarly associated with worse survival. For esophageal cancer, 254 abstracts were screened and 23 studies were included. Minimal literature addresses primary esophagectomy, but time to surgery over 8 weeks is associated with lower survival. In the neoadjuvant setting, longer time to surgery is associated with increased pathologic complete response, but also decreased survival. The optimal window for esophagectomy following neoadjuvant therapy is 6 to 8 weeks. Conclusions In the setting of the COVID-19 pandemic, timely resection of lung and esophageal cancer should be prioritized whenever possible based upon local resources and disease-burden.
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Affiliation(s)
- Scott C Fligor
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Savas T Tsikis
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sophie Wang
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ana Sofia Ore
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Benjamin G Allar
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ashlyn E Whitlock
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Rodrigo Calvillo-Ortiz
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Kevin Arndt
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Mark P Callery
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sidhu P Gangadharan
- Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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18
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Davis JA, Saunders R. Earlier Provision of Gastric Bypass Surgery in Canada Enhances Surgical Benefit and Leads to Cost and Comorbidity Reduction. Front Public Health 2020; 8:515. [PMID: 33102415 PMCID: PMC7554569 DOI: 10.3389/fpubh.2020.00515] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 08/10/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Effective provision of bariatric surgery for patients with obesity may be impeded by concerns of payers regarding costs or perceptions of patients who drop out of surgical programs after referral. Estimates of the cost and comorbidity impact of these inefficiencies in gastric bypass surgery in Canada are lacking but would aid in informing healthcare investment and resource allocation. Objectives: To estimate total and relative public payer costs for surgery and comorbidities (diabetes, hypertension, and dyslipidemia) in a bariatric surgery population. Methods: A decision analytic model for a 100-patient cohort in Canada (91% female, mean body mass index 49.2 kg/m2, 50% diabetes, 66% hypertension, 59% dyslipidemia). Costs include surgery, surgical complications, and comorbidities over the 10-year post-referral period. Results are calculated as medians and 95% credibility intervals (CrIs) for a pathway with surgery at 1 year (“improved”) compared with surgery at 3.5 years (“standard”). Sensitivity analyses were performed to test independent contributions to results of shorter wait time, better post-surgical weight loss, and randomly sampled cohort demographics. Results: Compared to standard care, the improved path was associated with reduction in patient-years of treatment for each of the three comorbidities, corresponding to a reduction of $1.1 (0.68–1.6) million, or 34% (26-41%) of total costs. Comorbidity treatment costs were 9.0- and 4.7-fold greater than surgical costs for the standard and improved pathways, respectively. Relative to non-surgical bariatric care, earlier surgery was associated with earlier return on surgical investment and 2-fold reduction in risk of prevalence of each comorbidity compared to delayed surgery. Conclusions: Comorbidity costs represent a greater burden to payers than the costs of gastric bypass surgery. Investments may be worthwhile to reduce wait times and dropout rates and improve post-surgical weight loss outcomes to save overall costs and reduce patient comorbidity prevalence.
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19
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Renfree SP, Makovicka JL, Chung AS. Risk factors for delay in surgery for patients undergoing elective anterior cervical discectomy and fusion. J Spine Surg 2019; 5:475-482. [PMID: 32042998 PMCID: PMC6989940 DOI: 10.21037/jss.2019.10.09] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is well-tolerated by most patients and commonly necessitates only a short hospital admission. Surgical delay after hospital admission, however, may result in longer hospital stays, consequently increasing hospital resource utilization. The current study evaluates risk factors for surgical delay in patients undergoing elective ACDF. METHODS A retrospective analysis of ACS-NSQIP data from 2006-2015 was performed. Patients undergoing elective ACDF were selected using current procedural terminology (CPT) codes (22251, 22252, 22554). A surgical delay was defined as surgery that occurred one day or later after initial hospital admission. Differences in outcomes between the non-delayed and delayed cohorts were evaluated with univariate analysis. Multivariate logistic regression was performed to identify risk factors for surgical delay. RESULTS There were a total of 771 (2.0%) surgical delays out of 39,371 patients undergoing elective ACDF from 2006-2015. Multivariate analysis found partially dependent functional status (OR 5.88; 95% CI: 4.48-7.71; P<0.001), totally dependent functional status (OR 18.22; 95% CI: 9.60-34.59; P<0.001), ASA class 4 (OR 2.73; 95% CI: 1.70-4.38; P<0.001), bleeding disorders (OR 1.75; 95% CI: 1.08-2.85; P=0.024), male sex (OR 1.19; 95% CI: 1.03-1.38; P=0.019), and chronic steroid use (OR 1.76; 95% CI: 1.30-2.37; P<0.001) as independent predictors of delay. Univariate analysis found surgical delay was associated with a higher rate of post-operative major adverse events (4.8% vs. 1.1%; P<0.001), mortality (1.0% vs. 0.2%; P<0.001) and greater than five-fold increase in total length of stay (9.52 vs. 1.65 days; P<0.001). CONCLUSIONS Impaired pre-operative functional status, a higher comorbidity burden, and chronic steroid use are risk factors for surgical delay, increased complications, and length of stay in patients undergoing elective ACDF. This is helpful information to consider given a rising incidence of cervical fusions in the Medicare population, a wide variation in costs, and increasing popularity of bundled-payment models. LEVEL OF EVIDENCE 3.
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Affiliation(s)
| | | | - Andrew S. Chung
- Orthopedic Surgery Residency, Mayo Clinic Arizona, Phoenix, Arizona, USA
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20
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Abstract
Objective To assess the impact of time between prostate cancer diagnosis on biopsy and definitive intervention with radical prostatectomy (RP) in regard to adverse pathologic outcomes using a large multi-surgeon database. Materials and methods We retrospectively reviewed 2,728 patients who underwent RP between 2005 and 2014. Patients were stratified according to biopsy Grade Group (GG). Pathologic outcomes were evaluated for patients with <2 months between biopsy and surgery and then at monthly intervals of up to 6 months. Adverse pathological outcomes were defined as Gleason upgrading from biopsy, the presence of extraprostatic extension (EPE, pT3a) or seminal vesicle invasion (SVI, pT3b), positive surgical margins, and lymph node positivity. The chi-squared test was used for statistical analysis. Results In total 2,310 patients met the inclusion criteria. Median time from biopsy to surgery was 83 days (range: 61–109 days). No difference was observed for patients in any risk category regarding the adverse pathologic outcomes, including GG upgrade from biopsy to prostatectomy, presence of EPE, SVI, positive surgical margins, and positive lymph node involvement, with delays of up to 6 months between biopsy and RP. Surgical margins were positive in 25% of cases with pT2 disease and 50.2% of cases with pT3 and greater disease. EPE and SVI were present in 24.5% and 7.5% of specimens, respectively. Conclusion Surgical delays of up to 6 months following prostate biopsy were not associated with an increased risk of GG upgrading, EPE, SVI, positive surgical margins, or lymph node involvement.
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Affiliation(s)
- Premal Patel
- Section of Urology, University of Manitoba, Winnipeg, MB, Canada,
| | - Ryan Sun
- Section of Urology, University of Manitoba, Winnipeg, MB, Canada,
| | - Benjamin Shiff
- Section of Urology, University of Manitoba, Winnipeg, MB, Canada,
| | - Kiril Trpkov
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada
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21
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Segreto FA, Beyer GA, Grieco P, Horn SR, Bortz CA, Jalai CM, Passias PG, Paulino CB, Diebo BG. Vertebral Osteomyelitis: A Comparison of Associated Outcomes in Early Versus Delayed Surgical Treatment. Int J Spine Surg 2018; 12:703-712. [PMID: 30619674 DOI: 10.14444/5088] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background The recommended timing of surgical intervention for vertebral osteomyelitis (VO) is controversial; however, most studies are not sufficiently powered. Our goal was to investigate the associated effects of delaying surgery in VO patients on in-hospital complications, neurologic deficits, and mortality. Methods Retrospective review of the National Inpatient Sample. Patients who underwent surgery for VO from 1998 to 2013 were identified using codes from the International Classification of Disease, Ninth Revision, Clinical Modification. Patients were stratified into groups based on incremental delay of surgery: 0-day delay (same-day surgery), 1-day delay, 2-day delay, 3- to 6-day delay, 7- to 14-day delay, and 14- to 30-day delay. Univariate analysis compared demographics and outcomes between groups. Multivariate logistic regression models calculated independent predictors of any complication, mortality, and neurologic deficits. A 0-day delay was the reference group. Results A total of 34 465 patients were identified. Delayed groups were older (same day: 53.5 vs. 7-14-day delay: 61.1) and had a higher Deyo-Charlson score (same day: 0.4901 vs. 14-30-day delay: 1.66), length of stay (same day: 4.2 vs. 14-30-day delay: 34.04 days), and total charges (same day: $63,390.78 vs. 14-30-day delay: $245,752.4), all P < .001. Delayed groups had higher surgical combined-approach rates (same day: 9.1% vs. 14-30-day delay: 31.5%) and lower anterior-approach rates (same day: 42.4% vs. 14-30-day delay: 24.2%). Delayed groups had increased mortality and complication rates. Regressions showed delayed groups as the strongest independent indicators of any complication (14-30-day delay: odds ratio [OR] 3.384), mortality (14-30-day delay: OR 10.658), and neurologic deficits (14-30-day delay: OR 3.464), all P < .001. Conclusion VO patients who operate within 24 hours of admission are more likely to have desirable outcomes. Patients with delayed surgery had a significantly increased risk of developing any complication, mortality, and discharging with neurologic deficits. Level of Evidence III. Clinical Relevance Medically fit patients may benefit from earlier surgical management in order to reduce risk of postoperative complications, improve outcomes, and reduce overall hospital costs.
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Affiliation(s)
- Frank A Segreto
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | | | - Preston Grieco
- Department of Orthopaedic Surgery, SUNY Downstate, Brooklyn, New York
| | - Samantha R Horn
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Cole A Bortz
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Cyrus M Jalai
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Peter G Passias
- Department of Orthopaedics, NYU Langone Medical Center, Hospital for Joint Diseases, New York, New York
| | - Carl B Paulino
- Department of Orthopaedic Surgery, SUNY Downstate, Brooklyn, New York
| | - Bassel G Diebo
- Department of Orthopaedic Surgery, SUNY Downstate, Brooklyn, New York
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22
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Lee JS, Eom JR, Lee JW, Choi KY, Chung HY, Cho BC, Yang JD. Safe delayed procedure of nipple reconstruction in poorly circulated nipple. Breast J 2018; 25:129-133. [PMID: 30557907 DOI: 10.1111/tbj.13167] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 12/11/2017] [Accepted: 12/12/2017] [Indexed: 11/30/2022]
Abstract
Nipple-areolar complex reconstruction represents the final step in breast reconstruction. However, there is no gold standard nipple reconstruction technique that addresses the issue of blood circulation in the flap, which is the most basic complication. Nipple reconstruction was performed in 21 patients. A delayed procedure was performed when a poor outcome was expected due to marginal pinpoint bleeding in the distal tip after flap elevation during nipple reconstruction. The delayed nipple reconstruction can be viewed as a safe and reliable method for improving nipple blood circulation, reducing complications, and enabling long-term nipple projection maintenance in high-risk patients.
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Affiliation(s)
- Joon Seok Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeung Ryeol Eom
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jeong Woo Lee
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Kang Young Choi
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Ho Yun Chung
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Byung Chae Cho
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Jung Dug Yang
- Department of Plastic and Reconstructive Surgery, School of Medicine, Kyungpook National University, Daegu, Korea
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Anthony CA, Duchman KR, Bedard NA, Gholson JJ, Gao Y, Pugely AJ, Callaghan JJ. Hip Fractures: Appropriate Timing to Operative Intervention. J Arthroplasty 2017; 32:3314-3318. [PMID: 28807469 DOI: 10.1016/j.arth.2017.07.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/06/2017] [Accepted: 07/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to (1) identify the incidence of surgical delay in hip fractures, (2) evaluate the time point surgical delay puts patients at increased risk for complications, and (3) identify risk factors for surgical delay in the setting of surgical management of hip fractures. METHODS A multi-center database was queried for patients of 60 years of age or older undergoing surgical treatment of a hip fracture. Surgical delay was defined by days from admission until surgical intervention. Univariate analyses and multivariate analyses were performed on all groups. RESULTS A total of 4215 patients underwent surgery for their hip fracture. Of those experiencing surgical delay, 3304 (78%) patients experienced surgical delay of ≥1 day, 1314 (31%) had delay of ≥2 days, and 480 (11%) experienced delay of ≥3 days. There was a significant difference in complications if patients experienced surgical delay of ≥2 days (P ≤ .01). Multivariate analyses identified multiple risk factors for delay of ≥2 days including congestive heart failure (odds ratio 3.09, 95% confidence interval 2.04-4.66) and body mass index ≥40 (odds ratio 2.31, 95% confidence interval 1.31-4.08). Subgroup analysis identified that patients undergoing total hip arthroplasty were not at risk for complications with surgical delay of ≥2 days. CONCLUSION Surgical delay of ≥2 days in the setting of hip fractures is common and confers an increased risk of complications in those undergoing non-total hip arthroplasty procedures. We recommend surgical intervention prior to 48 hours from hospital admission when possible. Healthcare systems can utilize our non-modifiable risk factors when performing quality assessment and cost accounting.
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Affiliation(s)
- Chris A Anthony
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Kyle R Duchman
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - James J Gholson
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Yubo Gao
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - Andrew J Pugely
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
| | - John J Callaghan
- Department of Orthopedics and Rehabilitation, University of Iowa, Iowa City, Iowa
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Yasunaga Y, Matsuo K, Tanaka Y, Yuzuriha S. Near-Infrared Irradiation Increases Length of Axial Pattern Flap Survival in Rats. Eplasty 2017; 17:e26. [PMID: 29242740 PMCID: PMC5590136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: We previously reported that near-infrared irradiation nonthermally induces long-lasting vasodilation of the subdermal plexus by causing apoptosis of vascular smooth muscle cells. To clarify the possible application of near-infrared irradiation to prevent skin flap necrosis, we evaluated the length of axial pattern flap survival in rats by near-infrared irradiation. Methods: A bilaterally symmetric island skin flap was elevated under the panniculus carnosus on the rat dorsum. Half of the flap was subjected to near-infrared irradiation just before flap elevation with a device that simulates solar radiation, which has a specialized contact cooling apparatus to avoid thermal effects. The length of flap survival of the near-infrared irradiated side was measured 7 days after flap elevation and compared with the nonirradiated side. Results: The irradiated side showed elongation of flap survival compared with the nonirradiated side (73.3 ± 11.7 mm vs 67.3 ± 14.9 mm, respectively, P = .03). Conclusions: Near-infrared irradiation increases the survival length of axial pattern flaps in rats.
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Affiliation(s)
- Yoshichika Yasunaga
- aDepartment of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan,Correspondence:
| | - Kiyoshi Matsuo
- aDepartment of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Yohei Tanaka
- bClinica Tanaka Anti-Aging Center, Matsumoto, Nagano, Japan
| | - Shunsuke Yuzuriha
- aDepartment of Plastic and Reconstructive Surgery, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
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Cornell CN. CORR Insights(®): Does N-terminal Pro-brain Type Natriuretic Peptide Predict Cardiac Complications After Hip Fracture Surgery? Clin Orthop Relat Res 2017; 475:1737-9. [PMID: 28144925 DOI: 10.1007/s11999-017-5262-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 01/24/2017] [Indexed: 01/31/2023]
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Abstract
Aim The aim of this literature review was to explore the reasons why some patients are not suitable for discharge following day surgery. Method A pragmatic, mixed-methods approach was used to undertake a critical evaluation of the literature and current practice to determine what is already known about discharge following day surgery. Thematic analysis was used to identify the main themes and issues, enabling recommendations to be made to reduce the incidence of patients unable to be discharged following day surgery. Findings The main themes or reasons for delayed discharge following day surgery identified from the literature review were: post-operative nausea and vomiting, post-operative pain, going late to theatre and social factors. These themes were supported by the findings of an unpublished audit carried out in one day surgery unit in an NHS healthcare organisation in the south of England between June and August 2014, which indicated that 54 out of 1,180 day surgery patients required an overnight stay during this 12-week period. The audit also showed that a patient going late to theatre had the greatest effect on discharge outcomes. Conclusion Recommendations for practice include: the introduction of post-operative nausea and vomiting risk scoring and prophylactic protocols; reorganisation of theatre lists to ensure patients have enough time to recover; and provision of information during the pre-assessment process about the requirement for a responsible adult escort to take patients home and stay with them for the first 24 hours. These changes may help NHS organisations to improve discharge outcomes for day surgery patients and reduce unplanned costs.
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Affiliation(s)
- Alison Rae
- Adult Nursing and Paramedic Science, University of Greenwich, London, England
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Phruetthiphat OA, Gao Y, Anthony CA, Pugely AJ, Warth LC, Callaghan JJ. Incidence of and Preoperative Risk Factors for Surgical Delay in Primary Total Hip Arthroplasty: Analysis From the American College of Surgeons National Surgical Quality Improvement Program. J Arthroplasty 2016; 31:2432-2436. [PMID: 27381373 DOI: 10.1016/j.arth.2016.05.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/25/2016] [Accepted: 05/25/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Total joint arthroplasty is a proven treatment for osteoarthritis of the knee and hip that has failed conservative treatment. While most of total joint arthroplasty is considered elective with surgery on the day of admission, a small subset of patients may require delay in surgery past the day of admission. Recently, surgical delay for primary total knee arthroplasty has been identified. However, the incidence, outcomes, and risk factors for delay in surgery before total hip arthroplasty (THA) have not been previously defined. QUESTIONS/PURPOSE In patients undergoing THA, we sought to define (1) the incidence of and risk factors for delay in surgery, (2) the postoperative complications between surgical delay and no surgical delay cohorts, and (3) association of the Charlson comorbidity index (CCI) in patients with delay of surgery. METHODS We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 7890 THAs performed between 2006 and 2010. Univariate and subsequent multivariate logistic regression analysis were then used to identify risk factors for surgical delay. Correlation between CCI and surgical delay in THA was evaluated. RESULTS One-hundred seventy-nine patients (2.31%) were identified as experiencing a surgical delay before THA. Multivariate analysis identified congestive heart failure (CHF) (P = .0038), bleeding disorder (P < .0001), sepsis (P < .0001), prior operation in past 30 days (P = .0001), dependent functional status (P < .0001), American Society of Anesthesiologists class 3 (P = .0001), American Society of Anesthesiologists class 4 (P = .0023), significant weight loss (P = .0109), and hematocrit <38% (P < .0001) as independent risk factors for delay in surgery. Compared with the nondelay cohort, those experiencing surgical delay before THA had higher rates of postoperative surgical (8.9% vs 3.1%, P < .0001) and medical complications (23.5% vs 10.1%, P < .0001). Mean CCI was higher in the THA surgical delay cohort (3.16 vs 2.24, P < .0001) compared with the nondelay group. CONCLUSION Surgical delay in patients undergoing THA may cause undue disruption in surgeon and hospital resource utilization. In an era of quality assessment and cost consciousness, it is important to understand that the short-term outcomes of elective, same day THA differ dramatically from those hospitalized for medical necessity before surgery. Surgeons should consider thorough medical evaluation in those with CHF, bleeding disorders, sepsis, significant weight loss, and hematocrit <38% before hospital admission.
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Affiliation(s)
- Ong-Art Phruetthiphat
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yubo Gao
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Chris A Anthony
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Andrew J Pugely
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - Lucian C Warth
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
| | - John J Callaghan
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Lowa
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Phruetthiphat OA, Gao Y, Vasta S, Zampogna B, Piperno A, Noiseux NO. Preoperative Risk Factors for, and Incidence of Delayed Surgery in Elective Primary Total Knee Arthroplasty After Hospital Admission: The ACS-NSQIP. J Arthroplasty 2016; 31:1413-6. [PMID: 26994648 DOI: 10.1016/j.arth.2015.04.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 04/17/2015] [Accepted: 04/19/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Approximately 600,000 total knee arthroplasties (TKA) are performed every year in the United States and the number of procedures has increased substantially every year. These demands may further strain the government, insurers, and patients struggling with increasing healthcare spending. A delay in proceeding to surgery after hospital admission may affect the overall healthcare costs. To our knowledge, the current literature has not addressed the incidence of, and preoperative risk factors for, a surgical delay in TKA. METHODS The ACS-NSQIP 2011 database was reviewed to identify patients undergoing elective primary total knee arthroplasty (TKA) using the Current Procedural Terminology (CPT) code 27447. 14,881 cases were no delay in proceeding to surgery after hospital admission while 139 cases were delayed for TKA. Risk factors or comorbidities contributing to surgical delay in TKA were identified. A univariate analysis of all patient parameters was conducted to measure the difference between the two cohorts. Finally, a multivariate logistic regression analysis was then conducted to identify risk factors or comorbidities for surgical delay. RESULTS There were 139 cases of surgical delay in TKA (0.93%). Congestive heart failure (P = 0.017), bleeding disorder (P <0.0001), sepsis (P <0.0001), a prior operation in the past 30 days (P <0.0001), dependent functional status (P <0.0001), ASA class 3 (P = 0.046), and hematocrit <38% (P <0.0001) were independent risk factors for a surgical delay. Postoperative medical complication (2.2% vs 0.8%, P < 0.0001) in surgical delay was significantly higher than non-delayed cohort. CONCLUSION The optimization of preoperative modifiable risk factors appears to be one of the best strategies to reduce delayed surgery and therefore costs in TKA.
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Affiliation(s)
- Ong-Art Phruetthiphat
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Iowa; Department of Orthopaedics, Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
| | - Yubo Gao
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Iowa
| | - Sebastiano Vasta
- Department of Orthopaedic and Trauma Surgery, University Campus Biomedico of Rome, Rome, Italy
| | - Biagio Zampogna
- Department of Orthopaedic and Trauma Surgery, University Campus Biomedico of Rome, Rome, Italy
| | | | - Nicolas O Noiseux
- Department of Orthopaedics and Rehabilitation, University of Iowa Hospital and Clinics, Iowa City, Iowa
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Loeb S, Folkvaljon Y, Robinson D, Makarov DV, Bratt O, Garmo H, Stattin P. Immediate versus delayed prostatectomy: Nationwide population-based study (.). Scand J Urol 2016; 50:246-54. [PMID: 27067998 DOI: 10.3109/21681805.2016.1166153] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The aim of this study was to compare the outcome of immediate versus delayed radical prostatectomy (RP) in men with low-grade prostate cancer. MATERIALS AND METHODS The study included a nationwide population-based cohort in the National Prostate Cancer Register of Sweden, of 7608 men with clinically localized, biopsy Gleason score 6 prostate cancer who underwent immediate or delayed RP in 1997-2007. Multivariable models compared RP pathology, use of salvage radiotherapy and prostate cancer mortality based on timing of RP (< 1, 1-2 or >2 years after diagnosis). Median follow-up was 8.1 years. RESULTS Men undergoing RP more than 2 years after diagnosis had a higher risk of Gleason upgrading [odds ratio 2.93, 95% confidence interval (CI) 2.34-3.68] and an increased risk of salvage radiotherapy [hazard ratio (HR) 1.90, 95% CI 1.41-2.55], but no significant increase in prostate cancer-specific mortality (HR 1.85, 95% CI 0.57-5.99). In competing risk analysis, 7 year prostate cancer-specific cumulative mortality was similar, at less than 1%, for immediate RP and active surveillance regardless of later intervention. Limitations of this study include the lack of data on follow-up biopsies and the limited follow-up time. CONCLUSION Men undergoing RP more than 2 years after diagnosis had more adverse pathological features and second line therapy, highlighting the trade-off in deferring immediate curative therapy. However, men with delayed RP constitute a minority with higher risk cancer among the much larger group of low-risk men initially surveilled, and the overall risk of prostate cancer mortality at 7 years was similarly low with immediate RP or active surveillance.
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Affiliation(s)
- Stacy Loeb
- a New York University and Manhattan Veterans Affairs Medical Center , New York , NY , USA
| | - Yasin Folkvaljon
- b Regional Cancer Centre Uppsala Örebro, Uppsala University Hospital , Uppsala , Sweden
| | - David Robinson
- c Department of Surgery and Perioperative Sciences, Urology and Andrology , Umeå University Hospital , Umeå , Sweden ;,d Department of Urology , Ryhov County Hospital , Jönköping , Sweden
| | - Danil V Makarov
- a New York University and Manhattan Veterans Affairs Medical Center , New York , NY , USA
| | - Ola Bratt
- e Department of Urology, CamPARI Clinic , Addenbrooke's Hospital , Cambridge , UK ;,f Department of Translational Sciences , Lund University , Lund , Sweden
| | - Hans Garmo
- g Faculty of Life Sciences and Medicine, Division of Cancer Studies , King's College London , London , UK
| | - Pär Stattin
- c Department of Surgery and Perioperative Sciences, Urology and Andrology , Umeå University Hospital , Umeå , Sweden ;,h Department of Surgical Sciences , Uppsala University , Uppsala , Sweden
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Vester-Andersen M, Lundstrøm LH, Buck DL, Møller MH. Association between surgical delay and survival in high-risk emergency abdominal surgery. A population-based Danish cohort study. Scand J Gastroenterol 2016; 51:121-8. [PMID: 26153059 DOI: 10.3109/00365521.2015.1066422] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE In patients with perforated peptic ulcer, surgical delay has recently been shown to be a critical determinant of survival. The aim of the present population-based cohort study was to evaluate the association between surgical delay by hour and mortality in high-risk patients undergoing emergency abdominal surgery in general. MATERIAL AND METHODS All in-patients aged ≥ 18 years having emergency abdominal laparotomy or laparoscopy performed within 48 h of admission between 1 January 2009 and 31 December 2010 in 13 Danish hospitals were included. Baseline and clinical data, including surgical delay and 90-day mortality were collected. The crude and adjusted association between surgical delay by hour and 90-day mortality was assessed by binary logistic regression. RESULTS A total of 2803 patients were included. Median age (interquartile range [IQR]) was 66 (51-78) years, and 515 patients (18.4%) died within 90 days of surgery. Over the first 24 h after hospital admission, each hour of surgical delay beyond hospital admission was associated with a median (IQR) decrease in 90-day survival of 2.2% (1.9-3.3%). No statistically significant association between surgical delay by hour and 90-day mortality was shown; crude and adjusted odds ratio with 95% confidence interval 1.016 (1.004-1.027) and 1.003 (0.989-1.017), respectively. Sensitivity analyses confirmed the primary finding. CONCLUSIONS In the present population-based cohort study of high-risk patients undergoing emergency abdominal surgery, no statistically significant adjusted association between mortality and surgical delay was found. Additional research in diagnosis-specific subgroups of high-risk patients undergoing emergency abdominal surgery is warranted.
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Affiliation(s)
- Morten Vester-Andersen
- a 1 Departments of Anaesthesiology and Intensive Care Medicine, Køge Hospital and Herlev Hospital , Herlev, Denmark
| | - Lars Hyldborg Lundstrøm
- b 2 Department of Anaesthesiology and Intensive Care Medicine, Nordsjællands Hospital , Hillerød, Denmark
| | - David Levarett Buck
- c 3 Department of Anaesthesiology and Intensive Care Medicine, Copenhagen University Hospital Rigshospitalet , Copenhagen, Denmark
| | - Morten Hylander Møller
- d 4 Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet , Copenhagen, Denmark
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