New surgical realities: implementation of an enhanced recovery after surgery protocol for gynecological laparoscopy—a prospective study

Background Multimodal rehabilitation allows optimization of functional recovery in surgery patients by reducing the postoperative stress and hospital stay duration, without increasing the morbidity and mortality. It is reportedly successful in other surgical disciplines, and guidelines for its application to gynecological surgery are available; however, most evidence for these guidelines is derived from observational and/or retrospective studies. Therefore, this study aimed to investigate the applicability of an enhanced recovery after surgery (ERAS) protocol in laparoscopic gynecological surgery and its influence on the postoperative stay, morbidity, mortality, and readmission, through a prospective approach. Methods This prospective cohort study was performed on 90 patients who underwent laparoscopic hysterectomy for benign causes from October 2017 to October 2019. Patients in whom the ERAS (ERAS group, n = 30) and traditional (control group, n = 60) protocols were implemented were compared. All patients were followed for 6 months. Results The groups were homogeneous and did not differ significantly with respect to the demographic characteristics (age, ASA score, body mass index), surgical indications, and surgery types. Adherence to the ERAS protocol was over 99%. The postoperative hospital-stay durations were 1.73 days (r = 1–3) and 2.97 days (r = 2–6) in the ERAS and control groups, respectively (p = 0.000). No significant intergroup differences were observed in the rates of complications and readmissions. Conclusions The ERAS protocol is applicable in laparoscopic gynecological surgery and can be implemented with good adherence. This can allow optimization of patient recovery by reducing the hospital stay duration, without increasing the rates of morbidity, mortality, or readmission.

EFFECT OF BREAST MILK ADMINISTERED ORALLY AS MINIMAL ENTERAL NUTRITION PRIOR TO TUBE FEEDING (OMEN) IN PRETERM INFANTS – SINGLE CENTER RANDOMIZED CONTROL TRIAL

BACKGROUND: Safety and clinical benets of early Minimum Enteral Nutrition (MEN) have been demonstrated by several trials. MEN is administered as tube feed bypassing the oral phase of digestion. Oropharyngeal administration of colostrum has shown positive trend to achieve feed tolerance. Aims: To study the effect of early initiation and subsequent continuation of minimal oral feeding prior to tube feeds on duration to achieve of full enteral feeds. METHODOLOGY: DESIGN: Open label RCT. Setting: Tertiary level care NICU. Participants: Hundred preterm very low birth weight neonates with no anomaly. Intervention: Infants received 3mL/kg/d of breastmilk or nothing via oral route q2h, beginning within 24-48h of birth which was continued until oral feedings initiated. In both groups tube feeds were introduced (10 ml/kg/d within 24-96 h) & increased (10-20 ml/kg/d) until 180 ml/kg/d. Oral feeding was based on infants cues and a post menstrual age of ≥32 week or weight ≥1250 gram. Outcome: Primary: Time to reach full tube feeds (days). Secondary: NEC, sepsis, mortality, and duration of hospital stay. Duration: 1 year. RESULTS: Infants in OMEN group reached full enteral feeds earlier (14.2 ± 9.0 vs 18.8 ± 11.8, p 0.03) and were discharged at relatively younger post menstrual age compared to those in the TMEN group. There was no signicant difference in the incidence of NEC, sepsis and mortality. CONCLUSION: Administration of small quantity of human milk orally before each tube feed led to earlier achievement of full volume enteral feeds.

Early and Mid-Term Results After Repair of Ischaemic Mitral Regurgitation with Complete Annuloplasty Ring and Incomplete Ring

Background: The choice of ring type for mitral valve (MV) repair is still debatable and usually is left to the surgeon's discretion. Aim: The aim of this study was to compare the early and mid-term results after repair of ischaemic mitral regurgitation (MR) with complete and incomplete annuloplasty rings. Methods: Collected data included preoperative assessment (age, sex, comorbidities, clinical status, NYHA grade, and the EURO score); intraoperative details (echocardiography, degree of MR, and cross-clamp time); and results (the length of ICU and hospital stay, duration and need for inotropes, duration of mechanical ventilation, and postoperative adverse events). Follow up after discharge included assessment of dyspnea status, the degree and progression of MR, and left ventricular function and dimensions. Results: The present study included 133 patients: 61 with incomplete rings and 72 with complete rings inserted. There was no significant difference in the rate of postoperative complications between the two groups, apart from a significantly higher percentage of patients with incomplete ring who required prolonged ventilation >24 hours (P = 0.002). There were no significant differences between the two groups, regarding the grade of residual MR (P = 0.464), postoperative dyspnea status (P = 0.723), 30-day mortality rate (P = 0.687), and mean duration of survival (P = 0.276). Conclusion: The choice of incomplete or complete annuloplasty ring was not associated with a marked difference in the early and midterm results of ischaemic MV repair.

Is COVID-19 that different in hemodialysis patients?: A single-center experience

Coronavirus disease 2019 (COVID-19) has affected millions worldwide, and in particular the care of patients on maintenance hemodialysis. These patients are thought to be at high risk of severe SARS-CoV-2 infection due to their older age and multiple comorbidities. The aim of this study was to compare hemodialysis and non-dialysis COVID-19 patients and find possible risk factors for mortality in hemodialysis patients. We developed a single-center retrospective cohort study, from March 1st to December 31st, 2020, that included maintenance hemodialysis patients hospitalized with laboratory confirmed SARS-CoV-2 infection, and age and sex propensity matched non-dialysis patients also hospitalized with a laboratory confirmed SARS-CoV-2 infection (1:1). A total of 34 hemodialysis patients were included, 70.6% male, mean age 76.5 years and on maintenance hemodialysis for 3.0 [0.5-23] years. At admission, 50.0% needed oxygen supply. Median hospital stay duration was 11.0 [5.8-17.0] days, and 38.2% developed bacterial superinfection. Maintenance hemodialysis patient mortality rate was 32.4%. When matched to the non-dialysis group, the hemodialysis group developed more often respiratory insufficiency (50.0% vs 8.8%, p<0.001) and had higher ferritin (1658.0 vs 623.5, p=0.004) and troponin T (130.0 vs 31.0, p<0.001) levels, whereas the non-dialysis group had higher transaminases levels. There was no statistical difference regarding hospitalization time, bacterial superinfection, or mortality between groups. When the logistic regression was performed, only bacterial superinfection was a predictor for mortality in hemodialysis COVID-19 patients (0.01 [0.00-0.26]). There was no difference in hospital stay nor in death rate between hemodialysis and non-dialysis COVID-19 patients. Despite these results, we must emphasize that mortality in the dialysis group was particularly high, with up to 32% of in-hospital mortality, and that bacterial superinfection has been shown to be an independent predictor of mortality. These results highlight the importance of interventions, such as full vaccination coverage, to mitigate the burden of COVID-19 in hemodialysis patients.

The Efficacy of Chest X-Ray for the Diagnosis and Follow-up in Young Adult COVID-19 Patients with Mild Dyspnea No Comorbid Diseases

Purpose: We investigated whether Chest X-Ray (CXR) could replace CT modality in the diagnosis and during the treatment of young adult COVID-19 patients with mild dyspnea with no comorbid diseases. Materials and Method: This retrospective study involved an examination of the records of a total of 956 patients hospitalized between March 1 and May 15, 2020. The study included a total of 64 patients, aged 21–60 years with mild dyspnea with no comorbid diseases and with COVID-19 infection confirmed by a polymerase chain reaction, who underwent a CXR at admission and CT imaging within 24 hours. The first CXR and CT images at the time of admission were evaluated in terms of lesions and localization. The clinical-radiological course of the diseases with CXR were also statistically evaluated. Results: CT was normal in 18/64 (28.2%) patients, all of whom also had normal CXR. The rest of the patients 46/64 (71.8%) with an abnormal CT, the CXR was normal in 18/46 (39.1%) and abnormal in 28/46 (60.9%). The time between the onset of complaints and admission to the hospital in patients with abnormal and normal CXR was 3.5 ± 2.3 days and 2.1 ± 1.1, which was statistically significant (p = 0.004). The hospital stay duration of the patient with abnormal and normal CXR was 9.6 ± 3.5 and 9.5 ± 3.4 (p=0.928), respectively, and was not statistically significant. Conclusion: CXR could be used in the diagnosis and follow-up of young adult COVID 19 patients with mild dyspnea no comorbid disease. In the case of early admission to the hospital, there is not a significant difference between using CXR or CT in the management of these patients. Therefore, the use of CXR in these patients groups will reduce the burden of CT units in pandemic conditions with limited resources.

Open versus laparoscopic cholecystectomy: a comparative study on patient parameters

Background: The advent of laparoscopic surgeries have heralded a giant leap for minimally invasive surgeries and are now being used as a primary modality due to its various benefits. The use of laparoscopic surgeries has been limited only by patient related factors and in certain scenarios by lack of infrastructure availability. The present study aimed to provide a comparative review of the traditional and minimally invasive modalities.Methods: The study employed a comparative prospective randomized study model with 100 subjects divided in two groups based on modality employed. The operative and post-operative parameters were noted and presented.Results: The study displayed that the advent of post-operative complications as well as hospital stay duration was higher in traditional laparoscopic cholecystectomy cases.Conclusions: The study reiterated the long known fact that laparoscopic surgeries in gall stones is favorable from the patient perspective but is riddled with unavailability due to financial and infrastructure based concerns.

The Effect of Cardiometry Guided Fluid Management on Outcome of Patients Presented for Intracranial Surgeries: Randomized Controlled Study

Background: Fluid management in neurosurgical patients is critical and important during the perioperative period. Electrical cardiometry (EC) is a new noninvasive technique for measuring cardiac output (COP). EC works based on the application of a high frequency transthoracic current and the analysis of variations of voltage in each heartbeat. The aim of this work is to compare the fluid management of intracranial surgeries using EC routine parameters. Methods: This is a prospective randomized, double-blinded controlled study was carried out on 70 patients of both genders aged > 21 years old, ASA physical status II or III, GCS 15 scheduled for elective craniotomy. Patients were divided into two equal groups at random; group A: standard management, group B: EC guided management. The primary outcome was the duration of intensive care unit (ICU) stay. Results: The ICU and hospital stay duration were significantly decreased in group B compared to group A. The mean total amount of infused volume of crystalloid solutions was significantly decreased in group B compared to group A. Hemodynamics, and number of patients received colloid, blood, vasopressor, and inotropes were insignificantly different between both groups. There was a significant increase in optic nerve sheath diameter in group A compared to group B at PACU and 24 h. Adverse events were comparable between both groups except encephalodema, which was significantly higher in group A. Conclusions: EC is an effective tool in COP measurement and a novel guide for fluid therapy as EC guided fluid therapy group was significantly decreased in ICU and hospital stay duration and the total amount of crystalloid with fewer adverse events.

AB0680 SARCOPENIA RATE IN COVID-19 SURVIVORS

Background:COVID-19 survivors may have high risks of developing sarcopenia, which is associated to handicap, poor quality of life, higher healthcare costs, increased risk of falls, increased mortality (1).Objectives:To assess sarcopenia rate (which has not been described yet) following COVID-19 hospitalization and to highlights features associated with sarcopenic vs. non-sarcopenic patients.Methods:Major confirmed COVID-19 patients undergoing intensive care unit (ICU) or Pneumology Department admission in Strasbourg University Hospital between March and June 2020 were prospectively included. Muscle and cardio-respiratory evaluations were performed 3 months after discharge. Sarcopenic patients were compared to non-sarcopenic ones. A second muscle assessment 6 months after discharge was performed in patients with pathologic muscle tests.Results:127 patients were included, 39 (30.7%) not requiring ICU care, 88 (69.3%) requiring ICU care. The cohort consisted of 71% male patients, with a median age of 63 years [28-82]. Forty-one-percent were obese (BMI>30 kg/m2). Most individuals had preexisting comorbidities (82 patients, 70%), mainly hypertension and diabetes mellitus. The median total hospital stay duration was 22 days and up to 89 days. At the 3 months assessment, 17/127 (13%) patients were diagnosed with sarcopenia which comprised 6/17 (35%) severe sarcopenia (4.7% of the total cohort). At the 6 months assessment, only 4/15 (27%) of the initial sarcopenic patients remained sarcopenic (3% of the total cohort) and 3 of these 4 patients had severe sarcopenia. BMI (26,3 vs. 29,3, p=0.03), COPD (20% vs. 3%, p=0.03), comorbidities (93% vs. 67%, p=0.04), total hospital stay duration (33 vs. 20 days, p=0.03) and ICU stay duration (33 vs. 13 days, p=0.01) were significantly associated with sarcopenic vs. no sarcopenic patients. However, there was no significant difference concerning cardio-pulmonary evaluations between these two groups.Conclusion:We here highlighted a sarcopenia prevalence at 3 and 6 months following a hospitalization for COVID-19 of 13% and 3% respectively, occurring mainly in patients with comorbidities. Sarcopenia was not associated to worse cardio-pulmonary results in comparison with non-sarcopenic patients.References:[1]Di Filippo L, De Lorenzo R, D’Amico M, Sofia V, Roveri L, Mele R, et al. COVID-19 is associated with clinically significant weight loss and risk of malnutrition, independent of hospitalisation: A post-hoc analysis of a prospective cohort study. Clinical Nutrition [Internet]. oct 2020. https://linkinghub.elsevier.com/retrieve/pii/S0261561420305896Disclosure of Interests:None declared

Comparison of topical honey and povidone iodine-based dressings for wound healing: a systematic review and meta-analysis

Objectives: In this review and meta-analysis, we analyse the evidence to compare the efficacy of honey and povidone iodine-based dressings on the outcome of wound healing. Method: A systematic literature search was performed using PRISMA guidelines in academic databases including MEDLINE, Scopus, Embase and CENTRAL. A meta-analysis was carried out to assess the effect of honey and povidone iodine-based dressings on mean healing duration, mean hospital stay duration and visual analogue scale (VAS) score of pain. Results: From the search, 12 manuscripts with a total of 1236 participants (mean age: 40.7±11.7 years) were included. The honey-based dressings demonstrated a medium-to-large effect in reduction of mean healing duration (Hedge's g: –0.81), length of hospital stay (–3.1) and VAS score (–1.2) as compared with the povidone iodine-based dressings. We present evidence (level 1b) in favour of using honey for improvement of wound recovery as compared with povidone iodine. Conclusion: This review and meta-analysis demonstrate beneficial effects of honey-based dressings over povidone iodine-based dressings for wound recovery.