Association between surgical indications, operative risk, and clinical outcome in infective endocarditis: a prospective study from the International Collaboration on Endocarditis.

Use of surgery for the treatment of infective endocarditis (IE) as related to surgical indications and operative risk for mortality has not been well defined.

The effect of surgical timing on the outcome of patients with neck of femur fracture

Aims: To investigate the effect of surgical timing (in hours versus after hours and weekdays versus weekends) on the outcome of patients with neck of femur fracture. Methods: Patients who were admitted to a single tertiary referral hospital for surgical management of femoral neck fractures over a continuous period from 1/11/2002 to 12/7/2012 were identified from medical records and the operating theatre database. Results: A consecutive series of 2334 patients were included in the study. Of the patients who underwent surgery during the weekday and during usual hours, 18 % (207/1135) experienced an adverse event, compared to 16 % (193/1199) outside of these times. The difference between the two groups was not significant (p = 0.17). The same conclusion was made for the comparison between those who had surgery during the week with those who had surgery on the weekend (17 %, 267/1546 and 17 %, 133/788, respectively, p > 0.05). The proportion of patients who underwent surgery during hours that experienced an adverse event was significantly higher than those undergoing surgery out of hours (18 %, 327/1789 and 13 %, 73/545, respectively, p = 0.0081). When adjusted for age, ASA score and pre-operative stay, there was no statistical difference between those different sub-groups. Conclusions: There was no difference in the rates of adverse events between patients who had surgery during hours and weekdays with those who had surgery after hours or weekends. The careful selection of patients with appropriate hospital staff, resources and adequate theatre access, surgery during after hours and weekends may be safely considered to prevent a delay in surgical treatment for patient with neck of femur fracture.

Colorectal preOperative surgical score (CrOSS) for mortality in major colorectal surgery

BACKGROUND: Colorectal surgery carries a significant mortality risk, with reported rates of 1-6% for elective surgery and up to 22% in the emergency setting. Both clinicians and patients will benefit from being able to predict the likelihood of death before surgery. Recently, we have described and validated two risk stratification models for colorectal surgery, the Barwon Health 2012 and Association Française de Chirurgie models. However, these models are not suitable for assessment at patient's bedside. The purpose of this study is to develop a simplified preoperative model capable of predicting mortality following colorectal surgery. METHODS: The new model is termed Colorectal preOperative Surgical Score (CrOSS). The development and internal validation of CrOSS was performed using a prospectively maintained colorectal database. External validation was performed using retrospective data. Univariate and multivariate analyses were performed in model development. Calibration and discrimination were used for model validation. RESULTS: There were 474 and 389 consecutive colorectal surgeries at Geelong Hospital and Western Hospital. Overall mortality rates were 5.16% and 1.03%, respectively. Significant predictors for mortality were as follows: age ≥70, urgent operation, albumin ≤30 g/L and congestive heart failure (receiver operating characteristic (ROC) = 0.870, calibration P-value = 0.937). The predicted risk of mortality was stratified according to the risk profile of 0.39-66.51%. When validated externally, CrOSS predicted mortality accurately (ROC = 0.847, calibration P-value = 0.199). CONCLUSIONS: A robust and simple preoperative model has been created to risk-stratify patients for colorectal surgery. This was successfully validated at another tertiary hospital.

Monitoring and evaluating surgical care: defining perioperative mortality rate and standardising data collection

BACKGROUND: Case volume per 100 000 population and perioperative mortality rate (POMR) are key indicators to monitor and strengthen surgical services. However, comparisons of POMR have been restricted by absence of standardised approaches to when it is measured, the ideal denominator, need for risk adjustment, and whether data are available. We aimed to address these issues and recommend a minimum dataset by analysing four large mixed surgical datasets, two from well-resourced settings with sophisticated electronic patient information systems and two from resource-limited settings where clinicians maintain locally developed databases. METHODS: We obtained data from the New Zealand (NZ) National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa (PMZ) and Port Moresby, Papua New Guinea (PNG). Information was sought on inclusion and exclusion criteria, coding criteria, and completeness of patient identifiers, admission, procedure, discharge and death dates, operation details, urgency of admission, and American Society of Anesthesiologists (ASA) score. Date-related errors were defined as missing dates and impossible discrepancies. For every site, we then calculated the POMR, the effect of admission episodes or procedures as denominator, and the difference between in-hospital POMR and 30-day POMR. To determine the need for risk adjustment, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site of age, admission urgency, ASA score, and procedure type. FINDINGS: 1 365 773 patient admissions involving 1 514 242 procedures were included, among which 8655 deaths were recorded within 30 days. Database inclusion and exclusion criteria differed substantially. NZ and Geelong records had less than 0·1% date-related errors and greater than 99·9% completeness. PMZ databases had 99·9% or greater completeness of all data except date-related items (94·0%). PNG had 99·9% or greater completeness for date of birth or age and admission date and operative procedure, but 80-83% completeness of patient identifiers and date related items. Coding of procedures was not standardised, and only NZ recorded ASA status and complete post-discharge mortality. In-hospital POMR range was 0·38% in NZ to 3·44% in PMZ, and in NZ it underestimated 30-day POMR by roughly a third. The difference in POMR by procedures instead of admission episodes as denominator ranged from 10% to 70%. Age older than 65 years and emergency admission had large independent effects on POMR, but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. INTERPRETATION: Hospitals can collect and provide data for case volume and POMR without sophisticated electronic information systems. POMR should initially be defined by in-hospital mortality because post-discharge deaths are not usually recorded, and with procedures as denominator because details allowing linkage of several operations within one patient's admission are not always present. Although age and admission urgency are independently associated with POMR, and ASA and case mix were not included, risk adjustment might not be essential because the relative odds between sites persisted. Standardisation of inclusion criteria and definitions is needed, as is attention to accuracy and completeness of dates of procedures, discharge and death. A one-page, paper-based form, or alternatively a simple electronic data collection form, containing a minimum dataset commenced in the operating theatre could facilitate this process. FUNDING: None.

Nutritional management of gastrointestinal surgical patients in Victoria's public hospitals

Aim: Poor nutritional status has negative effects on post-operative outcomes, further compounded by surgical stress and fasting, places gastrointestinal surgery patients at high risk of malnutrition. Recent published research has challenged historic surgical nutrition practices; however, changes to practice in Australia have been slow. The aim of this study was to investigate current nutritional management of gastrointestinal surgery patients and compare this with the best practice guidelines, while exploring enablers to implementation of best practice. Methods: A 30-question telephone survey was developed to explore demographics and nutritional management of gastrointestinal surgical patients during pre-admission, inpatient stay and post-operative care. Forty-one gastrointestinal surgery dietitians were identified and contacted from 31 public hospitals in Victoria, Australia, and invited to participate. Results: Twenty-five dietitians participated in the survey (response rate 61%). Very few dietitians (12%) were funded for pre-admission clinics or outpatient clinics, and, overwhelmingly, dietitians reported not being involved in nutritional decision-making, and reported feeling unsatisfied with current nutritional management of patients. Despite half the hospitals reporting following best practice guidelines, only 22% implemented guidelines completely. There was no correlation observed between dietitian experience, department size or full-time equivalents allocated to surgery and nutritional intervention; however, the presence of a care pathway made a significant difference to the dietitian's overall satisfaction with dietetic care (P = 0.002). Conclusions: Current nutritional management of gastrointestinal surgery patients in Victorian hospitals is far from best practice. The implementation of a care pathway is the most effective way of ensuring best practice nutritional management of gastrointestinal surgical patients.

Patterns of surgical treatment of breast cancer in Victoria

We analysed data on admissions to Victorian public hospitals for surgical treatment of breast cancer over the period July 1985 to December 1988. Of the 2993 women admitted, 28.7% received breast-preserving surgery. The probability of a woman being treated conservatively was dependent on age, with women aged less than 50 or more than 70 years more likely to receive breast-preserving surgery than women aged 50-69. There was an age-specific change, of marginal statistical significance, in the proportion of women receiving breast-preserving surgery over the period. The public hospitals admissions database is a potentially useful means of monitoring patterns of surgical treatment.

Surgical Site Infection in a University Hospital in Northeast Brazil

We examined prevention of surgical site infection (SSI) in a tertiary teaching hospital in northeast Brazil, from January 1994 to December 2003. The survey included 5,742 patients subjected to thoracic, urologic, vascular and general surgery. The criteria for diagnosing SSI were those of the Centers for Disease Control, USA, and the variables of the National Nosocomial Infection Surveillance risk index were used. Data analysis revealed that anesthetic risk scores, wound class and duration of surgery were significantly associated with SSI. A total of 296 SSIs were detected among the 5,742 patients (5.1%). The overall incidence of SSI was 8.8% in 1994; it decreased to 3.3% in 2003. In conclusion, the use of educational strategies, based on guidelines for SSI prevention reduced SSI incidence. Appropriate management of preoperative, intraoperative, and postoperative incision care, and a surveillance system based on international criteria, were useful in reducing SSI rates in our hospital

Aspectos clínico e cirúrgicos do tumor mamário canino: clinical and surgical evolution

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Surgical treatment of gynaecomastia in a Saanen goat

Background: Gynaecomastia in male goats is characterized by abnormal development of the mammary gland. Enlarged udder may be observed cranially to the scrotum, which can occasionally reach the size of the testicles. The udder may carry functional glands and impair the animal's reproductive performance and welfare. The case of a successful surgical treatment of gynaecomastia in a high reproductive performance Saanen buck-goat is reported in the present study.Material, Methods & Results: The animal was admitted presenting significant augmentation of the mammary glands, which was clinically diagnosed as gynaecomastia. The male goat owned optimal phenotypic characteristics for the Saanen breed, which had been producing high performance descendents. The mammary glands had been impairing the goat's locomotion and sexual performance. Manual milking resulted in great amount of milk secretion. The animal presented anorexia and impaired sexual performance. After clinical and laboratorial evaluation, the animal was submitted to radical mastectomy. An elliptic skin incision was performed around each mammary gland. Subcuticular blunt dissection was accomplished to isolate the mammarian tissue from the abdominal muscular layer and the spermatic chord. The excised mass was sampled for histological assessment. Subcuticular layer and skin closure was carried in a routine fashion. Hygienization of the surgical wound was performed with 2,5% PVP-I solution for ten days. Additionally, an association of penicillin G benzathine and streptomycin, and fluxinin meglumine were also given. The surgical procedure was successfully accomplished without any peroperative complication. The excised mass was sampled for anatomic/histological assessment. Macroscopically, the left mammary gland presented 22 cm in length, 12 cm wide and 26 cm in diameter. The right gland presented 16 cm in length, 7 cm wide and 13,5 cm in diameter. The microscopic assessment revealed hyperplasia of the glandular ducts. No abnormalities resembling malignant mammary neoplasms or degeneration were observed. At the end of the treatment, the animal was completely recovered. The animal convalesced satisfactorily and surgical wound healed completely within the first 10 days post-op. The goat was not culled and returned to normal reproductive activity. Within 12 months of follow-up, the animal was able to produce high milk yield performance progenies.Discussion: This case report presented relevant aspects of the surgical management of gynaecomastia, especially to veterinary practitioners dealing with milk goats. Gynaecomastia is not as common as other reproductive disorders in domestic animals. In opposition to the findings of the present study, other trials revealed that gynaecomastia usually does not affect fertility, libido, ejaculate parameters and sexual performance of goats. However, it is important to consider that neoplasic disorders such as mammary adenocarcinoma may be present, even though these are rare complications. Last but not least, the decision making on mastectomy in the present study was crucial in order to reestablish the animal's welfare and its functionality in the farms reproduction program.

The role of obesity as a modifying factor in patients undergoing non-surgical periodontal therapy

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Maintaining Tissue Perfusion in High-Risk Surgical Patients: A Systematic Review of Randomized Clinical Trials

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Patient perceptions about anesthesia and anesthesiologists before and after surgical procedures

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Efficacy of surgical versus conservative treatment in esophageal perforation: a systematic review of case series studies

PURPOSE: To evaluate the efficacy of surgical treatment for esophageal perforation. METHODS: A systematic review of the literature was performed. We conducted a search strategy in the main electronic databases such as PubMed, Embase and Lilacs to identify all case series. RESULTS: Thirty three case series met the inclusion criteria with a total of 1417 participants. The predominant etiology was iatrogenic (54.2%) followed by spontaneous cause (20.4%) and in 66.1% the localization was thoracic. In 65.4% and 33.4% surgical and conservative therapy, respectively, was considered the first choice. There was a statistically significance different with regards mortality rate favoring the surgical group (16.3%) versus conservative treatment (21.2%) (p<0.05). CONCLUSION: Surgical treatment was more effective and safe than conservative treatment concerning mortality rates, although the possibility of bias due to clinical and methodological heterogeneity among the included studies and the level of evidence that cannot be ruled out.

Surgical risk tests related to cardiopulmonary postoperative complications: comparison between upper abdominal and thoracic surgery

PURPOSE: To investigate if tests used in the preoperative period of upper abdominal or thoracic surgeries are able to differentiate the patients that presented cardiopulmonary postoperative complications. METHODS: Seventy eight patients, 30 submitted to upper abdominal surgery and 48 to thoracic surgery were evaluated. Spirometry, respirometry, manovacuometry, six-minute walk test and stair-climbing test were performed. Complications from immediate postoperative to discharge from hospital were registered. RESULTS: The postoperative complications rate was 17% in upper abdominal surgery and 10% in thoracic surgery. In the univariate regression, the only variable that kept the correlation with postoperative complications in the upper abdominal surgery was maximal expiratory pressure. In thoracic surgery, the maximal voluntary ventilation, six-minute walk test and time in stair-climbing test presented correlation with postoperative complications. After multiple regression only stair-climbing test continued as an important risk predictor in thoracic surgery. CONCLUSION: The respiratory pressure could differentiate patients with complications in upper abdominal surgery, whereas in thoracic surgery, only spirometric values and exercise tests could differentiate them.