Enhanced Recovery After Surgery program for elective abdominal surgery at three Victorian hospitals

The aim of this study was to evaluate the anaesthesia care of an enhanced recovery after surgery (ERAS) program for patients having abdominal surgical in Victorian hospitals. The main outcome measure was the number of ERAS items implemented following introduction of the ERAS program. Secondary endpoints included process of care measures, outcomes and hospital stay. We used a before-and-after design; the control group was a prospective cohort (n=154) representing pre-existing practice for elective abdominal surgical patients from July 2009. The introduction of a comprehensive ERAS program took place over two months and included the education of surgeons, anaesthetists, nurses and allied health professionals. A post-implementation cohort (n=169) was enrolled in early 2010. From a total of 14 ERAS-recommended items, there were significantly more implemented in the post-ERAS period, median 8 (interquartile range 7 to 9) vs 9 (8 to 10), P <0.0001. There were, however, persistent low rates of intravenous fluid restriction (25%) and early removal of urinary catheter (31%) in the post-ERAS period. ERAS patients had less pain and faster recovery parameters, and this was associated with a reduced hospital stay, geometric mean (SD) 5.7 (2.5) vs 7.4 (2.1) days, P=0.006. We found that perioperative anaesthesia practices can be readily modified to incorporate an enhanced recovery program in Victorian hospitals.

Understanding in-vivo abrasion fatigue or common suture materials used in arthroscopic and open shoulder surgery

In orthopaedic surgery the reattachment of tendon to bone requires suture materials that have stable and durable properties to allow healing at the tendon-bone interface. Failure rates of this type of surgery can be as high as 25%. While the tissue suture interface is a weak link, proportions of these failures are caused by in-vivo abrasion of the suture with bone and suture anchor materials. Abrasion of the suture material results from the movement of the suture through the eyelet by the surgeon during surgery, or with limb movement after surgery as the suture is not rigidly restrained within the eyelet. During movement the suture is subjected to bending and frictional forces that can lead to fatigue induced failure. This paper investigates the mechanism of bending abrasion fatigue induced failure of number two grade braided sheath only and braided sheath/multifilament core sutures. Sutures were oscillated over a stainless steel wire at low frequency under load in a dry state to simulate the bending and frictional forces between suture and eyelet. Failure mechanism was determined by video microscopy of the suture during abrasion combined with optical microscopy analysis of partially and fully abraded sutures. Braided only structures had high friction loading on the small number of fibres at the abrasion interface. This caused rapid single fibre breakages that accumulate to cause suture failure. The addition of ultra-high molecular weight polyethylene core fibres to a braided suture distributed the applied load across multiple fibres at the abrasion interface. This improved abrasion resistance by 15-20 times that of braided sheath alone.

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Validity of the Beck Depression Inventory as a screening tool for a clinical mood disorder in Bariatric surgery candidates

Background : The Beck Depression Inventory (BDI) is one of the most commonly used instruments to assess depression in persons with obesity. While it has been validated in normal and psychiatric populations, in obese populations, its validity remains uncertain. This study aimed to investigate the validity and reliability of the BDI-IA and BDI-II in severely obese bariatric surgery candidates.

Methods : Consecutive new candidates at a bariatric surgery clinic were invited to participate in the study by their consulting surgeon. All candidates were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID-I); 118 completed the BDI-IA and 83 completed the BDI-II. Two hundred one patients (response rate, 88 %) participated in the study. The current sample (82 % female) had an average body mass index of 42.83 ± 6.34 and an average age of 45 ± 12 years.

Results : Based on the SCID-I, 54 candidates (26.9 %) met the criteria for a mood disorder, with 37 meeting the criteria for current major depressive disorder. Individuals diagnosed with a clinical mood disorder had significantly higher scores on the BDI (BDI-IA, 23.59 ± 9.69 vs. 12.76 ± 8.29; BDI-II, 22.93 ± 5.22 vs. 11.25 ± 8.44). Our results indicated that, as a screening tool for a clinical mood disorder, the BDI-II had an optimal cutoff of 13, with a sensitivity of 100 and specificity of 67.75.

Conclusions : Results indicated that the BDI-IA should not be used as a tool to measure depressive symptomatology in obese bariatric surgery candidates. No cutoff was identified with adequate sensitivity and specificity, and over 20 % of patients were misclassified. As a screening tool for a clinical mood disorder, the BDI-II was adequate; however, prevalence rates were significantly overestimated.

Characterization of the improvement in depressive symptoms following Bariatric surgery

Background : The Beck Depression Inventory (BDI) has been frequently employed as a measure of depression in studies of obesity, with the majority of studies reporting an improvement in scores following weight loss. Given the potential similarity in obesity-related and depressive symptoms, it is uncertain whether all components of depression would improve equally with weight loss.

Method : The study included obese patients who had undergone laparoscopic adjustable gastric banding (LAGB) surgery and had completed BDIs at baseline and 1 year after surgery. Two groups of patients were included, a general background group (N = 191, mean age = 41 ± 9, mean BMI = 43 ± 8) and a group identified as experiencing elevated depressive symptoms based on BDI scores ≥23 (EDS group; (N = 67, mean age = 40 ± 9, mean BMI = 45 ± 7).

Results : Overall, BDI scores fell for both groups, background group at baseline 17 ± 9–8 ± 7 at 1 year and for the EDS group at baseline 30 ± 5–14 ± 10 at 1 year. Patient scores on the negative self-attitude subscale were significantly greater than the two other subscales and showed the greatest improvement 1 year following LAGB. Preexisting antidepressant therapy had little or no association on the BDI scores or on its change following weight loss.

Conclusion : High rates of depression are continually reported in obesity, as is a remarkable decrease in depressive symptoms following weight loss. Negative attitudes towards one’s self appears to be driving elevated BDI scores rather than the overlap in physical symptoms between obesity and depression.

Confirmatory factor analysis of the Beck Depression inventory in obese individuals seeking surgery

Background : The Beck Depression Inventory (BDI) is frequently employed as measure of depression in studies of obesity. The aim of the study was to assess the factorial structure of the BDI in obese patients prior to bariatric surgery.

Methods : Confirmatory factor analysis was conducted on the current published factor analyses of the BDI. Three published models were initially analysed with two additional modified models subsequently included. A sample of 285 patients presenting for Lap-Band® surgery was used.

Results : The published bariatric model by Munoz et al. was not an adequate fit to the data. The general model by Shafer et al. was a good fit to the data but had substantial limitations. The weight loss item did not significantly load on any factor in either model. A modified Shafer model and a proposed model were tested, and both were found to be a good fit to the data with minimal differences between the two. A proposed model, in which two items, weight loss and appetite, were omitted, was suggested to be the better model with good reliability.

Conclusions : The previously published factor analysis in bariatric candidates by Munoz et al. was a poor fit to the data, and use of this factor structure should be seriously reconsidered within the obese population. The hypothesised model was the best fit to the data. The findings of the study suggest that the existing published models are not adequate for investigating depression in obese patients seeking surgery.

Motivation, readiness to change, and weight loss following adjustable gastric band surgery

High levels of readiness to change (RTC) are considered critical to the long-term success of weight management programs including bariatric surgery. However, there are no data to support this assertion. We hypothesize that RTC level will not influence weight outcomes following surgery. In 227 consecutive patients undergoing adjustable gastric banding surgery, we recorded reasons for seeking surgery, and RTC measured with the University of Rhode Island Change Assessment. Scores were blinded until study completion. The primary outcome measure was percentage of excess BMI loss at 2 years (%EBMIL-2); others included compliance and surgical complications. Of 227 subjects, 204 (90%) had weight measurement at 2 years. There was no significant correlation between RTC score and %EBMIL-2 (r = 0.047, P = 0.5). Using the median split for RTC score the lowest 102 subjects mean %EBMIL-2 was 52.9 ± 26.9% and the highest 52.2 ± 28.3%, P = 0.869. There was no weight loss difference between highest and lowest quartiles, or a nonlinear relationship between weight loss and RTC score. There was no significant relationship between RCT score and compliance, or likelihood of complications. Those motivated by appearance were more likely to be younger women who lost more weight at 2 years. Poor attendance at follow-up visits was associated with less weight loss, especially in men. Measures of RTC did not predict weight loss, compliance, or surgical complications. Caution is advised when using assessments of RTC to predict outcomes of bariatric surgery.

Implementation of a quality care management system for patients with arthritis of the hip and knee

The Orthopaedic Unit of the Repatriation General Hospital (RGH) in Adelaide, South Australia has implemented a quality care management system for patients with arthritis of the hip and knee. The system not only optimises conservative management but ensures that joint replacement surgery is undertaken in an appropriate and timely manner. This new service model addresses identified barriers to service access and provides a comprehensive, coordinated strategy for patient management. Over 4 years the model has reduced waiting times for initial outpatient assessment from 8 to 3 months and surgery from 18 to 8 months, while decreasing length of stay from 6.3 to 5.3 days for hips and 5.8 to 5.3 days for knees. The service reforms have been accompanied by positive feedback from patients and referring general practitioners in relation to the improved coordination of care and enhanced efficiency in service delivery.

What is known about the topic? Several important initiatives both overseas and within Australia have contributed significantly to the development of this model of care. These include the UK National Health Service ‘18 weeks’ Project, the Western Canada Waiting List Project, the New Zealand priority criteria project, the Queensland Health Orthopaedic Physiotherapy Screening Clinic, and most importantly the Melbourne Health–University of Melbourne Orthopaedic Waiting List Project where a wide range of models were explored across Victorian hospitals from 2005 and the Multi-Attribute Prioritisation Tool (MAPT) was developed, validated and tested. This project became the Osteoarthritis Hip and Knee Service (OAHKS) and was operationalised in the Victorian healthcare system from 2012. These initiatives examined and addressed various aspects of management systems for patients with arthritis of the hip and knee in their particular setting.

What does this paper add? The development of this system is an extension of what is already known and is the first to encompass a comprehensive and coordinated strategy across all stages of the care management pathway for this patient group. Their management extends from the initial referral to development and implementation of a management plan, including surgery if assessed as necessary and organisation of long-term post operative follow up as required. By detailing the elements, key processes and measurable outcomes of the service redesign this paper provides a model for other institutions to implement a similar initiative.

What are the implications for practitioners? An important aspect of the design process was practitioner acceptance and engagement and the ability to improve their capacity to deliver services within an efficient and effective model. Intrinsic to the model’s development was assessment of practitioner satisfaction. Data obtained including practitioner surveys indicated an increased level of both satisfaction with the redesigned management service, and confidence in it to deliver its intended improvements.

Motion analysis of a robotic assisted surgery and microsurgery system - experimental verification

Motion analysis of a parallel robot assisted minimally invasive surgery/microsurgery system (PRAMiSS) and the control structures enabling it to achieve milli/micromanipulations under the constraint of moving through a fixed penetration point or so-called remote centre-of-motion (RCM) are presented in this article. Two control algorithms are proposed suitable for minimally invasive surgery (MIS) with submillimeter accuracy and for minimally invasive micro-surgery (MIMS) with submicrometer accuracy. The RCM constraint is performed without having any mechanical constraint. Control algorithms also apply orientation constraint preventing the tip to orient relative to the soft tissues due to the robot movements. Experiments were conducted to verify accuracy and effectiveness of the proposed control algorithms for MIS and MIMS operations. The experimental results demonstrate accuracy and performance of the proposed position control algorithms.

Remote centre-of-motion control algorithms of 6-RRCRR parallel robot assisted surgery system (PRAMiSS)

In this paper a 6-RRCRR parallel robot assisted minimally invasive surgery/microsurgery system (PRAMiSS) is introduced. Remote centre-of-motion (RCM) control algorithms of PRAMiSS suitable for minimally invasive surgery and microsurgery are also presented. The programmable RCM approach is implemented in order to achieve manipulation under the constraint of moving through the fixed penetration point. Having minimised the displacements of the mobile platform of the parallel micropositioning robot, the algorithms also apply orientation constraint to the instrument and prevent the tool tip to orient due to the robot movements during the manipulation. Experimental results are provided to verify accuracy and effectiveness of the proposed RCM control algorithms for minimally invasive surgery.

A comparison of the psychological outcomes of cosmetic surgical procedures

Studies of psychological outcomes of cosmetic surgery generally provide low standards of evidence due to significant methodological limitations and few studies have explored the outcomes of surgery types other than breast reduction or have compared post-operative outcomes for different surgery types. This study therefore aimed to explore the psychological outcomes and post-operative satisfaction of cosmetic surgery and compare the outcomes and satisfaction of participants undergoing different procedures.

Surveys were administered to a sample of 142 elective cosmetic surgery patients prior to surgery and six months after surgery. The surveys included standardised measures of body image (appearance evaluation, appearance orientation, body areas satisfaction), self-esteem, and mental health (psychiatric disturbance, anxiety, depression, dysmorphic concerns).

The findings revealed high rates of post-operative satisfaction and significant improvements in several dimensions of body image (appearance evaluation and body area satisfaction) and mental health (anxiety, depression, and dysmorphic concerns), but not self-esteem. Breast augmentation patients reported significantly higher improvement on appearance evaluation, significantly higher ratings of how likely they thought it was that they had achieved, or would achieve, what they were looking for in having the procedure, and a trend to report that the overall result of surgery was better than or as expected than rhinoplasty patients.

It is recommended that future research clarifies the degree to which self-esteem and indices of mental health improve after cosmetic surgery and fully establishes the impact of different procedures on psychological outcomes.

Preoperative immunonutrition and its effect on postoperative outcomes in well-nourished and malnourished gastrointestinal surgery patients: a randomised controlled trial

Background/Objectives:
Invasive procedures such as surgery cause immunosuppression, leading to increased risk of complications, infections and extended hospital stay. Emerging research around immune-enhancing nutrition supplements and their ability to reduce postoperative complications and reduce treatment costs is promising. This randomised controlled trial aims to examine the effect of preoperative immunonutrition supplementation on length of hospital stay (LOS), complications and treatment costs in both well-nourished and malnourished gastrointestinal surgery patients.

Subjects/Methods:
Ninety-five patients undergoing elective upper and lower gastrointestinal surgery were recruited. The treatment group (n=46) received a commercial immuno-enhancing supplement 5 days preoperatively. The control group (n=49) received no supplements. The primary outcome measure was LOS, and secondary outcome measures included complications and cost.

Results:
A nonsignificant trend towards a shorter LOS within the treatment group was observed (7.1±4.1 compared with 8.8±6.5 days; P=0.11). For malnourished patients, this trend was greater with hospital stay reduced by 4 days (8.3±3.5 vs 12.3±9.5 days; P=0.21). Complications and unplanned intensive care admission rates were very low in both the groups. The average admission cost was reduced by AUD1576 in the treatment group compared with the control group (P=0.37).

Conclusions:
Preoperative immunonutrition therapy in gastrointestinal surgery has the potential to reduce the LOS and cost, with greater treatment benefit seen in malnourished patients; however, there is a need for additional research with greater patient numbers.