Preoperative counseling and management

397 Background:The timing and the extent of Advanced Care Planning (ACP) in patients with pancreatic ductal adenocarcinoma (PDAC) undergoing curative-intent resection are generally dictated by the surgeon performing the operation. The aim of this study is to evaluate surgeons’ insights, perceptions, and biases regarding preoperative ACP. We hypothesize that many surgeons harbor significant reservations about extensive preoperative ACP. Methods:A qualitative investigation using 1:1 interviews with 40 open-ended questions were conducted with convenience sample. Data accrual continued until theme saturation was achieved. Grounded theory approach was used for data coding and analysis. Results:A total of 10 interviews were conducted with expert pancreatic surgeons from 6 medical centers—6 males and 4 females. The median number of years in practice was 15 (IQR 13-30) and the median number of pancreatic cancer cases performed per year was 52 (IQR 39-75). During preoperative counseling all surgeons discuss the possibility of recurrence and postoperative complications but attempt to motivate patients by emphasizing hope, optimism, and fact that surgery offers the only opportunity for cure. 90% of surgeons report no formal training in ACP. All surgeons report comfort with end of life conversations when death is imminent, but most lack experience with in-depth preoperative ACP. All surgeons emphasized that ACP should be led by a physician that both knows the patient well and understands the complexity of PDAC management. All surgeons recognized potential benefits of ACP, including delivery of goal-concordant care (60%), increased prognostic awareness (40%), and better life planning (40%). 50% report discussing in-depth ACP related to perioperative complications, but not long-term oncologic outcome. 80% of surgeons report that they actively steer away from in-depth ACP during preoperative counseling. Barriers to in-depth ACP reported by surgeons include taking away hope (70%), lack of time (50%) and concern for sending “mixed messages” (50%). Further, 50% of surgeons perceived that extensive preoperative ACP is not appropriate for patients with PDAC undergoing curative-intent resection. Most surgeons (60%) believe that ACP should occur as a process throughout the disease and in-depth discussions were more appropriate during postoperative visits (30%) and/or recurrence (60%). Conclusions:Despite recognizing potential benefits, most pancreatic surgeons report actively avoiding in-depth ACP conversations prior to curative-intent surgery. Surgeons had difficulty articulating the best time for ACP and felt that ACP should occur as a continuum throughout the course of treatment, with the depth of the discussion echoing the disease progression and patients’ readiness for such conversation. Future studies could evaluate patients’ perspective on the timing and the dose of ACP.

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Can specific preoperative counseling increase the likelihood a woman will choose postmastectomy breast reconstruction?

The American Journal of Surgery ◽

10.1016/s0002-9610(01)00788-7 ◽

2001 ◽

Vol 182 (6) ◽

pp. 649-653 ◽

Cited By ~ 16

Author(s):

Christina A Finlayson ◽

Tracey A MacDermott ◽

Jyoti Arya

Keyword(s):

Breast Reconstruction ◽

Preoperative Counseling

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Patient Selection and Preoperative Counseling

Principles of Microsurgical Techniques in Infertility ◽

10.1007/978-1-4684-4010-2_5 ◽

1982 ◽

pp. 95-119 ◽

Cited By ~ 2

Author(s):

Niels H. Lauersen

Keyword(s):

Patient Selection ◽

Preoperative Counseling

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Opioid Prescribing in Patients Undergoing Neck Dissections With Short Hospitalizations

Otolaryngology ◽

10.1177/0194599820957980 ◽

2020 ◽

pp. 019459982095798

Author(s):

Grace L. Banik ◽

Kristen L. Kraimer ◽

Maisie L. Shindo

Keyword(s):

Pain Management ◽

Head And Neck ◽

Neck Dissection ◽

Opioid Prescription ◽

Multidisciplinary Collaboration ◽

Opioid Prescribing ◽

The Mean ◽

Preoperative Counseling ◽

Group 2 ◽

Group 1

Objective To evaluate postoperative opioid prescribing in patients undergoing neck dissections with short hospitalizations. Study Design Retrospective cohort study. Setting Tertiary academic hospital. Methods The study population included patients who underwent lateral neck dissections with or without an associated head and neck procedure and required hospitalization for ≤3 days from 2012 to 2019. Interventions to decrease opioid utilization, including preoperative counseling, multimodality pain management, and multidisciplinary collaboration, were implemented in September 2016. Patients were divided into 2 groups: preintervention (group 1) and postintervention (group 2). The mean quantity of opioids prescribed during hospitalization, at discharge, and in refills was calculated in morphine milligram equivalents (MME). Results A total of 407 patients were included in the analysis: 223 patients in group 1 and 184 patients in group 2 (42.3% female, 89.4% white; average age, 55.2 years [95% CI, 53.6-56.9]). The mean opioid quantity prescribed in unilateral neck dissection alone decreased from 353.9 MME (95% CI, 266.7-441.2) in group 1 to 113.3 MME (95% CI, 87.8-138.7) in group 2 ( P < .001; effect size, 1.0). Statistically significant decreases in mean opioid quantity prescribed were also observed in unilateral neck dissection in combination with thyroidectomy, parotidectomy, glossectomy, or tonsillectomy. The percentage of patients requiring opioid prescription refills was not statistically different between the groups. Conclusion This study demonstrates that the quantity of opioids prescribed in patients undergoing neck dissections and associated head and neck procedures with short hospitalizations can be reduced to as low as 100 to 125 MME with preoperative counseling, multimodality pain management, and multidisciplinary collaboration.

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The Use of Crisis Intervention in the Rehabilitation of Laryngectomees

Journal of Speech and Hearing Disorders ◽

10.1044/jshd.3703.323 ◽

1972 ◽

Vol 37 (3) ◽

pp. 323-328 ◽

Cited By ~ 9

Author(s):

Virginia Sanchez-Salazar ◽

Anne Stark

Keyword(s):

Los Angeles ◽

Crisis Intervention ◽

Los Angeles County ◽

Speech Pathology ◽

University Of Southern California ◽

The Social ◽

Speech Pathologist ◽

Working Together ◽

Preoperative Counseling

Laryngectomee rehabilitation at the Los Angeles County-University of Southern California Medical Center’s Speech Pathology Clinic is based on crisis intervention theory. The speech pathologist and the social worker, working together to totally rehabilitate laryngectomees, identified four potentially crisis-precipitating events. The laryngectomee rehabilitation staff designed and applied interventive and preventive techniques for these situations. They include preoperative counseling of the patient as soon as possible after the need for the laryngectomy is confirmed and related to him, follow-up ward visits with him and his family, team counseling of the patient before his discharge, outpatient clinic visits after discharge, participation in the hospital’s chapter of the Lost Chord Club, and group interaction therapy one hour a week for 10 weeks.

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Patient-Specific 3-Dimensional Modeling and Its Use for Preoperative Counseling of Patients Undergoing Hip Arthroscopy

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967118794645 ◽

2018 ◽

Vol 6 (9) ◽

pp. 232596711879464 ◽

Cited By ~ 3

Author(s):

Sean Childs ◽

Zachary McVicker ◽

Ryan Trombetta ◽

Hani Awad ◽

John Elfar ◽

...

Keyword(s):

Hip Arthroscopy ◽

Patient Specific ◽

3 Dimensional ◽

Dimensional Modeling ◽

Preoperative Counseling

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Nutritional Deficiencies and Bariatric Surgery

10.1093/med/9780190608347.003.0014 ◽

2018 ◽

Author(s):

Anthony B. Mozer ◽

Konstantinos Spaniolas ◽

Walter J. Pories

Keyword(s):

Bariatric Surgery ◽

Oral Intake ◽

Emergency Department Visits ◽

Nutritional Deficiencies ◽

Vitamin Supplementation ◽

Behavioral Modification ◽

Poor Oral Intake ◽

Preoperative Counseling ◽

Disproportionate Number

Dietary intolerance and poor oral intake account for a disproportionate number of emergency department visits and readmissions after bariatric surgery. Micronutrient, vitamin, and protein deficiencies can occur after both malabsorptive and restrictive weight-loss operations, and they are best mitigated against by conscientious preoperative counseling and vigilance in follow-up. Routine vitamin supplementation can prevent the need for unnecessary laboratory testing, while symptoms of dumping syndrome can frequently be managed with dietary and behavioral modification alone. Alternative enteral feeding access for alimentary supplementation can be safely performed surgically or with assistance by interventional radiology, and should be considered in the management of perforation, early anastomotic leak, surgical revision, or patients with refractory malnourishment.

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