Preoperative exclusive enteral nutrition (EEN) improves nutritional status, reduces intestinal inflammation, and likely improves surgical outcomes. Crohn\'s disease exclusion diet with partial enteral nutrition (CDED) also reduces intestinal inflammation but its safety preoperatively is unknown. This single-blinded, multicentre, randomised controlled trial of three preoperative nutritional therapies aimed to assess the feasibility of recruiting and retaining patients and collecting primary and secondary effectiveness outcomes. Adults undergoing elective Crohn\'s disease surgery with a body mass index (BMI) > 18.5 kg/m2 and without significant weight loss were eligible to participate. Patients were randomly assigned to six weeks of preoperative EEN, CDED, or standard care. Feasibility, nutritional, radiological, and surgical outcomes were recorded. Over 18 months, 48 patients were screened, 17 (35%) were randomised, and 13/17 (76%) patients were retained in the intervention phase. It was feasible to collect primary and secondary effectiveness data; at day 30, three patients had Clavien Dindo Grade 2 complications, and 10 had no complications. Nutritional therapy adherence of patients retained in the study was high. Recruitment and retention of patients who need elective Crohn\'s disease surgery for preoperative nutritional therapy is possible, although a shorter duration may improve EEN completion. The impact on surgical outcomes should be assessed in a larger study.

Background: Sleep deprivation and disturbances in circadian rhythms may hinder surgical performance and decision-making capabilities. Solid organ transplantations, which are technically demanding and often begin at uncertain times, frequently during nighttime hours, are particularly susceptible to these effects. This study aimed to assess how transplant operations conducted during daytime versus nighttime influence both patient and graft outcomes and function. Methods: simultaneous pancreas-kidney transplants (SPKTs) conducted at the University Hospital of Leipzig from 1998 to 2018 were reviewed retrospectively. The transplants were categorized based on whether they began during daytime hours (8 a.m. to 6 p.m.) or nighttime hours (6 p.m. to 8 a.m.). We analyzed the demographics of both donors and recipients, as well as primary outcomes, which included surgical complications, patient survival, and graft longevity. Results: In this research involving 105 patients, 43 SPKTs, accounting for 41%, took place in the daytime, while 62 transplants (59%) occurred at night. The characteristics of both donors and recipients were similar across the two groups. Further, the rate of (surgical) pancreas graft-related complications and reoperations (daytime 39.5% versus nighttime 33.9%; p = 0.552) were also not statistically significant between both groups. In this study, the five-year survival rate for patients was comparable for both daytime and nighttime surgeries, with 85.2% for daytime and 86% for nighttime procedures (p = 0.816). Similarly, the survival rates for pancreas grafts were 75% for daytime and 77% for nighttime operations (p = 0.912), and for kidney grafts, 76% during the day compared to 80% at night (p = 0.740), indicating no significant statistical difference between the two time periods. In a multivariable model, recipient BMI > 30 kg/m2, donor age, donor BMI, and cold ischemia time > 15 h were independent predictors for increased risk of (surgical) pancreas graft-related complications, whereas the timepoint of SPKT (daytime versus nighttime) did not have an impact. Conclusions: The findings from our retrospective analysis at a big single German transplant center indicate that SPKT is a reliable procedure, regardless of the start time. Additionally, our data revealed that patients undergoing nighttime transplants have no greater risk of surgical complications or inferior results concerning long-term survival of the patient and graft. However, due to the small number of cases evaluated, further studies are required to confirm these results.

BACKGROUND: Across surgery, marginalized individuals experience worse postoperative outcomes. These disparities stem from the interplay between multiple factors.
METHODS: We introduced a novel framework to assess the role of barriers to access and bias in surgical complications (the uChicago Health Inequity Classification System, CHI-CS) in the setting of morbidity and mortality conference and assessed impact through pre and post implementation surveys.
RESULTS: Access and bias were related to surgical complications in 14 ​% of cases. 97 ​% reported enhanced M&M presentations with the grading system, and 47 ​% reported a change in decision-making or practice style. Although post-implementation response rate was low, there were improvements in self-reported confidence and comfort in recognizing and discussing these issues.
CONCLUSIONS: Implementation of the CHI-CS framework to discuss bias and access to care positively impacted the way providers view, discuss, and process health inequities.

The prevalence of liver disease is rising and more patients with liver disease are considered for surgery each year. Liver disease poses many potential complications to surgery; therefore, assessing perioperative risk and optimizing a patient\'s liver health is necessary to decrease perioperative risk. Multiple scoring tools exist to help quantify perioperative risk and can be used in combination to best educate patients prior to surgery. In this review, we go over the various scoring tools and provide a guide for clinicians to best assess and optimize perioperative risk based on the etiology of liver disease.

BACKGROUND: Open reduction internal fixation (ORIF) remains the gold standard for adult distal humerus fractures (DHF). However, indications for total elbow arthroplasty (TEA) continue to expand and the incidence of primary and salvage TEA for DHF has increased. The objective of this study was to compare complication and reoperation rate for acute versus delayed primary and salvage TEA performed for DHF.
METHODS: Patients who underwent TEA for DHF were identified in the PearlDiver database. Patients were sorted into three cohorts: (1) acute TEA (within 2 weeks of diagnosis), (2) delayed TEA (between 2 weeks and 6 months after diagnosis), and (3) salvage TEA (after failed ORIF, malunion, nonunion, delayed treatment between 6 months-1 year or post-traumatic arthritis). Multivariate analysis was utilized to assess for confounding variables and covariates when identify differences in complications between cohorts.
RESULTS: 788 patients underwent acute TEA, 213 patients underwent delayed TEA, and 422 patients underwent salvage TEA after DHF. The incidence of PJI (8.5% vs. 3.4%, odds ratio (OR) 2.60, P=0.002) and triceps injury (2.4% vs. 0.4%, OR 6.29, P=0.012) were higher in the delayed compared to acute cohort. The incidence of revision (8.5% vs. 2.1%, OR 3.76, P< 0.001), periprosthetic fracture (4.3% vs. 1.1%, OR 3.64, P=0.002), PJI (14.7% vs 3.4%, OR 4.36, P< 0.001), triceps injury (2.6% vs. 0.4%, OR 5.70, P=0.008), and wound complications (6.9% vs 2.9%, OR 2.33, P=0.002) were higher in the salvage compared to acute cohort. There was an increased rate of revision (8.5% vs. 1.9%, OR 6.08, P=0.002) in the salvage compared to delayed cohort.
CONCLUSIONS: Patients undergoing salvage TEA after DHF have increased rates of at 2 years postoperatively including revision, periprosthetic fracture, PJI, triceps injury, and wound complications. The salvage cohort also had an increased risk of revision when compared to the delayed cohort. However, other than revision rates, patients in the salvage and delayed cohorts have similar postoperative complication rates.

UNASSIGNED: Bladder outlet obstruction (BOO) is common in older adults. Many older adults who pursue surgery have additional vulnerabilities affecting surgical risk, including frailty. A clinical tool that builds on frailty to predict surgical outcomes for the spectrum of BOO procedures would be helpful to aid in surgical decision-making but does not currently exist.
UNASSIGNED: Medicare beneficiaries undergoing BOO surgery from 2014 to 2016 were identified and analyzed using the Medicare MedPAR, Outpatient, and Carrier files. Eight different BOO surgery categories were created. Baseline frailty was calculated for each beneficiary using the Claims-Based Frailty Index (CFI). All 93 variables in the CFI and the 17 variables in the Charlson Comorbidity Index were individually entered into stepwise logistic regression models to determine variables most highly predictive of complications. Similar and duplicative variables were combined into categories. Calibration curves and tests of model fit, including C statistics, Brier scores, and Spiegelhalter P values, were calculated to ensure the prognostic accuracy for postoperative complications.
UNASSIGNED: In total, 212,543 beneficiaries were identified. Approximately 42.5% were prefrail (0.15 ≤ CFI < 0.25), 8.7% were mildly frail (0.25 ≤ CFI < 0.35), and 1.2% were moderately-to-severely frail (CFI ≥0.35). Using stepwise logistic regression, 13 distinct prognostic variable categories were identified as the most reliable predictors of postoperative outcomes. Most models demonstrated excellent model discrimination and calibration with high C statistic and Spiegelhalter P values, respectively, and high accuracy with low Brier scores. Calibration curves for each outcome demonstrated excellent model fit.
UNASSIGNED: This novel risk assessment tool may help guide surgical prognostication among this vulnerable population.

BACKGROUND: The benefit of chemoprophylaxis (CPX) agents in preventing venous thromboembolism must be weighed against potential risks. Current literature regarding the efficacy of CPX after laminectomies with or without fusion is limited, with no clear consensus to inform guidelines.
OBJECTIVE: This study evaluated the association between CPX and surgical complications after lumbar laminectomy with and without fusion.
METHODS: Retrospective study of patients at a single large academic institution.
METHODS: The medical records of patients who underwent lumbar laminectomies with or without lumbar fusion from 2018 to 2020 were reviewed for demographics, surgical characteristics, CPX agents, postoperative complications, epidural hematomas, and wound drainage. Patients receiving CPX (n = 316) were compared with patients not receiving CPX (n = 316) via t test following propensity score matching, and patients on CPX were further stratified by fusion status.
RESULTS: The CPX group had higher body mass index and American Society of Anesthesiologists grades. Rates of venous thromboembolism, epidural hematomas, infections, postoperative incision and drainage, transfusions, wound dehiscence, and reoperation were not associated with CPX. Moist dressings were more frequent, and average days of drain duration were longer with CPX. Overall postoperative complication rate and length of stay (LOS) were greater with CPX. The fusion subgroup had a lower Charlson Comorbidity Index, had a lower American Society of Anesthesiologists grade, was younger, had more women, and underwent more minimally invasive laminectomies. While estimated blood loss, operative times, and LOS were significantly greater in the fusion group, there was no difference in rate of intraoperative and postoperative complications.
CONCLUSIONS: CPX after lumbar laminectomies with or without fusion was not associated with increased rates of epidural hematomas, wound complications, or reoperation. Patients receiving CPX had more postoperative cardiac complications, but it is possible that surgeons were more likely to prescribe CPX for higher-risk patients. They also had higher rates of ileus and moist dressings, greater LOS, and longer length of drain duration. Patients who underwent lumbar laminectomy with fusion on CPX tended to be lower risk yet incurred greater blood loss, operative times, LOS, cardiac complications, and hematomas/seromas than patients not undergoing fusion.
CONCLUSIONS: This retrospective study compared surgical complications of lumbar laminectomies in patients who received chemoprophylaxis vs patients who did not. Chemoprophylaxis was not associated with increased rates of epidural hematomas, wound complications, or reoperation, but it was associated with higher rates of postoperative cardiac complications and ileus.
METHODS:

Background: Transient hypoparathyroidism (TH) is the main post-thyroidectomy complication, significantly impacting surgical outcomes, hospitalization length, and perceived perceived quality of life understood as mental and physical well-being. This study aims to identify possible associated risk factors. Methods: We analyzed 238 thyroidectomies (2020-2022), excluding instances of partial surgery, primary hyperparathyroidism, neck irradiation history, and renal failure. The variables considered were as follows: demographics, histology, autoimmunity, thyroid function, pre- and postoperative Vitamin D levels (where available), type of surgery, number of incidentally removed parathyroid glands (IRP), and surgeons\' experience (>1000 thyroidectomies, <500, in training). Univariate analysis applied: χ2, Fisher\'s exact test for categorical variables, and Student\'s t-test for continuous variables. Subsequently, logistic multivariate analysis with stepwise selection was performed. Results: Univariate analysis did not yield statistically significant results for the considered variables. The \'No Complications\' group displayed a mean age of 55 years, whereas the TH group showed a mean age of 51 (p-value = 0.055). We considered this result to be marginally significant. Subsequently, we constructed a multivariate logistic model. This model (AIC = 245.02) indicated that the absence of incidental parathyroidectomy was associated with the age class >55 years, presenting an odds ratio (OR) of 9.015 (p-value < 0.05). Simultaneously, the age class >55 years exhibited protective effects against TH, demonstrating an OR of 0.085 (p-value < 0.01). Similarly, the absence of incidental parathyroidectomy was found to be protective against TH, with an OR of 0.208 (p-value < 0.01). Conclusions: Multivariate analysis highlighted that having \"No IRP\" was protective against TH, while younger age was a risk factor. Surgeon experience does not seem to correlate with IRP or outcomes, assuming there is adequate tutoring and a case volume close to 500 to ensure good results. The effect of reimplantation has not been evident in transient hypoparathyroidism.

BACKGROUND: Pelvic exenteration (PE) is the last resort for achieving a complete cure for pelvic cancer; however, it is burdensome for patients. Minimally invasive surgeries, including robot-assisted surgery, have been widely used to treat malignant tumors and have also recently been used in PE. This study aimed to evaluate the safety and efficacy of robot-assisted PE (RPE) by comparing the outcomes of open PE (OPE) with those of conventional laparoscopic PE (LPE) for treating pelvic tumors.
METHODS: Following the ethics committee approval, a multicenter retrospective analysis of patients who underwent pelvic exenteration between January 2012 and October 2022 was conducted. Data on patient demographics, tumor characteristics, and perioperative outcomes were collected. A 1:1 propensity score-matched analysis was performed to minimize group selection bias.
RESULTS: In total, 261 patients met the study criteria, of whom 61 underwent RPE, 90 underwent OPE, and 110 underwent LPE. After propensity score matching, 50 pairs were created for RPE and OPE and 59 for RPE and LPE. RPE was associated with significantly less blood loss (RPE vs. OPE: 408 mL vs. 2385 ml, p < 0.001), lower transfusion rate (RPE vs. OPE: 32% vs. 82%, p < 0.001), and lower rate of complications over Clavien-Dindo grade II (RPE vs. OPE: 48% vs. 74%, p = 0.013; RPE vs. LPE: 48% vs. 76%, p = 0.002).
CONCLUSIONS: This multicenter study suggests that RPE reduces blood loss and transfusion compared with OPE and has a lower rate of complications compared with OPE and LPE in patients with locally advanced and recurrent pelvic tumors.

BACKGROUND: Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation.
METHODS: It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months.
RESULTS: Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications.
CONCLUSIONS: The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up.
UNASSIGNED: Level II.