Management of Sigmoid Volvulus Avoiding Sigmoid Resection

Acute sigmoid volvulus is typically caused by an excessively mobile and redundant segment of colon with a stretched mesenteric pedicle. When this segment twists on its pedicle, the result can be obstruction, ischemia and perforation. A healthy, 18-year-old Caucasian woman presented to the emergency department complaining of cramping abdominal pain, distention, constipation and obstipation for the last 72 h, accompanied by nausea, vomiting and abdominal tenderness. The patient had tympanitic percussion tones and no bowel sounds. She was diagnosed with acute sigmoid volvulus. Although urgent resective surgery seems to be the appropriate treatment for those who present with acute abdominal pain, intestinal perforation or ischemic necrosis of the intestinal mucosa, the first therapeutic choice for clinically stable patients in good general condition is considered, by many institutions, to be endoscopic decompression. Controversy exists on the decision of the time, the type of definitive treatment, the strategy and the most appropriate surgical technique, especially for teenagers for whom sigmoid resection can be avoided

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Comparison of lumbar plexus - sciatic nerve block vs femoral - obturator - sciatic nerve block for arthroscopic anterior cruciate ligament: prospective randomised study

For the arthroscopic ACL repair, three nerves must be blocked, the femoral, the obturator and the sciatic nerve. We investigated the feasibility of performing ACL reconstruction under dual-guided blockade of obturator with femoral and sciatic nerves. Furthermore, we propose a novel method for the assessment of obturator nerve block.Subsequently, we conducted a randomized controlled study in order to compare and evaluate the intraoperative and postoperative outcome of PLPS nerve block and that of femoral, obturator and sciatic (FOS) nerve block as a method of anesthesia, in performing ACL reconstruction.Material and metheds: Initially, fifty-seven patients undergoing anterior cruciate ligament repair were studied. Neurostimulating needles were guided out-of-plane by ultrasound. To induce the obturator nerve block, 10 ml of ropivacaine 0.5% were injected, followed by block assessment for 30 minutes by examining the patient lift and left down the leg.Next, 106 patients referred for elective arthroscopic ACL reconstruction were divided in two groups. The first group received combined femoral–obturator–sciatic nerve block (FOS Group) under dual guidance, whereas the second group received posterior lumbar plexus block under neurostimulation and sciatic nerve block under dual guidance (PLPS Group).Results: The sonographic recognition of obturator nerve was easy and quick in all cases. Time for applying the block was119.9 ± 79.2 sec. After performing femoral-sciatic blocks, the inflation of tourniquet resulted in VAS score of > 0 in 2/57 patients and operation in 12/57. Total dose of fentanyl was 120.1 ± 64.6 μg and of midazolam 1.86 ± 0.8 mg. In 1 patient there was conversion to general anesthesia.In the second phase of the study, the two groups were comparable in terms of age, sex, BMI and athletic activity. The time needed to perform the nerve blocks was significantly shorter for the FOS group (p 0 σε 2/57 ασθενείς, και κατά τη διάρκεια του χειρουργείου σε 12/57. Η συνολική δόση φεντανύλης ήταν 120.1 ± 64.6 μg και μιδαζολάμης 1.86 ± 0.8 mg. Σε 1 ασθενή έγινε μετατροπή της τεχνικής σε γενική αναισθησία.Στη δεύτερη φάση της μελέτης, οι δύο ομάδες ήταν συγκρίσιμες για την ηλικία, το φύλο, το ΔΜΣ και το επίπεδο αθλητικής δραστηριότητας. Ο χρόνος που χρειάστηκε για τη διενέργεια των περιφερικών αποκλεισμών ήταν σημαντικά μικρότερος για την ομάδα ΜΘΙ (p < 0.005). Παρόμοια, οι βαθμολογίες VAS κατά την εμφύσηση της ίσχαιμης περίδεσης και κατά τη λήψη των μοσχευμάτων ήταν σημαντικά υψηλότερη (p < 0.005) στην ομάδα ΟΟΠΙ. Τέλος, οι ασθενείς σε αυτή την ομάδα ανέφεραν υψηλότερες βαθμολογίες VAS μετεγχειρητικά και κατανάλωσαν περισσότερη μορφίνη.Συμπεράσματα: Ο περιφερικός νευρικός αποκλεισμός του μηριαίου, θυροειδούς και ισχιακού νεύρου υπό διπλή καθοδήγηση για την αρθροσκοπική αποκατάσταση του ΠΧΣ είναι μία ασφαλής και γοητευτική αναισθητική επιλογή. Η αναγνώριση του θυροειδούς νεύρου με τη σύγχρονη χρήση των υπερήχων είναι εύκολη και ο αποτελεσματικότητα του αποκλεισμού μπορεί να εκτιμηθεί με μία απλή κλινική δοκιμασία. Η μελέτη αυτή υποστηρίζει τεκμηριωμένα τη χρήση των περιφερικών νευρικών αποκλεισμών ως αποκλειστική αναισθησιολογική μέθοδο για την αρθροσκοπική αποκατάσταση ΠΧΣ σε περιβάλλον ταχείας διακίνησης ασθενών

Supraventricular Arrhythmias after Thoracotomy: Is There a Role for Autonomic Imbalance?

Supraventricular arrhythmias are common rhythm disturbances following pulmonary surgery. The overall incidence varies between 3.2% and 30% in the literature, while atrial fibrillation is the most common form. These arrhythmias usually have an uneventful clinical course and revert to normal sinus rhythm, usually before patent’s discharge from hospital. Their importance lies in the immediate hemodynamic consequences, the potential for systemic embolization and the consequent long-term need for prophylactic drug administration, and the increased cost of hospitalization. Their incidence is probably related to the magnitude of the performed operative procedure, occurring more frequently after pneumonectomy than after lobectomy. Investigators believe that surgical factors (irritation of the atria per se or on the ground of chronic inflammation of aged atria), direct injury to the anatomic structure of the autonomic nervous system in the thoracic cavity, and postthoracotomy pain may contribute independently or in association with each other to the development of these arrhythmias. This review discusses currently available information about the potential mechanisms and risk factors for these rhythm disturbances. The discussion is in particular focused on the role of postoperative pain and its relation to the autonomic imbalance, in an attempt to avoid or minimize discomfort with proper analgesia utilization

Demystifying the Value of Minimal Clinically Important Difference in the Cardiothoracic Surgery Context

The aim of this review is to describe the different statistical methods used in estimating the minimal clinically important difference (MCID) for the assessment of quality of life (QOL)-related and clinical improvement interventions, along with their implementation in cardiothoracic surgery. A thorough literature search was performed in three databases (PubMed/Medline, Scopus, Google Scholar) for relevant articles from 1980 to 2022. We included articles that implemented and assessed statistical methods used to estimate the concept of MCID in cardiothoracic surgery. MCID has been successfully implemented in several medical specialties. Anchor-based and distribution-based methods are the most common approaches when evaluating the MCID. Nonetheless, we found only five studies investigating the MCID in the context of cardiothoracic surgery. Four of them used anchor-based approaches, and one used both anchor-based and distribution-based methods. MCID values were very variable depending on the methods applied, as was the clinical context of the study. The variables of interest were certain QOL measuring questionnaires, used as anchors. Multiple anchors and methods were applied, leading to different estimations of MCID. Since cardiothoracic surgery is related to important perioperative morbidity, MCID might represent an important and efficient adjunct tool to interpret clinical outcomes. The need for MCID methodology implementation is even higher in patients with heart failure undergoing cardiac surgery. More studies are needed to validate different MCID methods in this context.</p

Demystifying the Value of Minimal Clinically Important Difference in the Cardiothoracic Surgery Context

The aim of this review is to describe the different statistical methods used in estimating the minimal clinically important difference (MCID) for the assessment of quality of life (QOL)-related and clinical improvement interventions, along with their implementation in cardiothoracic surgery. A thorough literature search was performed in three databases (PubMed/Medline, Scopus, Google Scholar) for relevant articles from 1980 to 2022. We included articles that implemented and assessed statistical methods used to estimate the concept of MCID in cardiothoracic surgery. MCID has been successfully implemented in several medical specialties. Anchor-based and distribution-based methods are the most common approaches when evaluating the MCID. Nonetheless, we found only five studies investigating the MCID in the context of cardiothoracic surgery. Four of them used anchor-based approaches, and one used both anchor-based and distribution-based methods. MCID values were very variable depending on the methods applied, as was the clinical context of the study. The variables of interest were certain QOL measuring questionnaires, used as anchors. Multiple anchors and methods were applied, leading to different estimations of MCID. Since cardiothoracic surgery is related to important perioperative morbidity, MCID might represent an important and efficient adjunct tool to interpret clinical outcomes. The need for MCID methodology implementation is even higher in patients with heart failure undergoing cardiac surgery. More studies are needed to validate different MCID methods in this context.</jats:p