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BackgroundThere is currently conflicting evidence surrounding the effects of obesity on postoperative outcomes. Previous studies have found obesity to be associated with adverse events, but others have found no association. The aim of this study was to determine whether increasing body mass index (BMI) is an independent risk factor for development of major postoperative complications.MethodsThis was a multicentre prospective cohort study across the UK and Republic of Ireland. Consecutive patients undergoing elective or emergency gastrointestinal surgery over a 4‐month interval (October–December 2014) were eligible for inclusion. The primary outcome was the 30‐day major complication rate (Clavien–Dindo grade III–V). BMI was grouped according to the World Health Organization classification. Multilevel logistic regression models were used to adjust for patient, operative and hospital‐level effects, creating odds ratios (ORs) and 95 per cent confidence intervals (c.i.).ResultsOf 7965 patients, 2545 (32·0 per cent) were of normal weight, 2673 (33·6 per cent) were overweight and 2747 (34·5 per cent) were obese. Overall, 4925 (61·8 per cent) underwent elective and 3038 (38·1 per cent) emergency operations. The 30‐day major complication rate was 11·4 per cent (908 of 7965). In adjusted models, a significant interaction was found between BMI and diagnosis, with an association seen between BMI and major complications for patients with malignancy (overweight: OR 1·59, 95 per cent c.i. 1·12 to 2·29, P = 0·008; obese: OR 1·91, 1·31 to 2·83, P = 0·002; compared with normal weight) but not benign disease (overweight: OR 0·89, 0·71 to 1·12, P = 0·329; obese: OR 0·84, 0·66 to 1·06, P = 0·147).ConclusionOverweight and obese patients undergoing surgery for gastrointestinal malignancy are at increased risk of major postoperative complications compared with those of normal weight.

Background: Perioperative use of opioids is common in surgical practice and frequently results in troublesome opioid-related side effects that often lead to suboptimal postsurgical outcomes. As such, multiple studies have sought to identify alternatives that may reduce reliance on opioid-based perioperative pain management. Recently, it has been shown that patient education and patient involvement in care positively impact surgical outcomes. This study evaluates how patient education regarding the role of endogenous beta-endorphins in reducing pain and the opposing effect of opioid analgesics impacts opioid consumption and mood after surgery. Methods: Patients scheduled for breast augmentation were divided into two groups, A and B. Both groups received identical multimodal anesthesia regimens; however, only patients in group B were educated on the role of endogenous beta-endorphins in pain control and mood enhancement, and how opioids block their action. Results: Patients in the group receiving preoperative education on the analgesic and mood-enhancing role of endogenous beta-endorphins and how opioids block their action consumed significantly less opioids and had better postsurgical outcomes as determined by self-reported measures of pain level and mood/sense of well-being. Conclusions: The findings of this study suggest that opioid use was significantly reduced and patients’ mood/sense of well-being was significantly enhanced when patients received preoperative education on the oppositional relationship between beta-endorphins and opioids. Such patient education may be linked to a significant reduction in opioid use and improved patient mood/sense of well-being, especially when combined with opioid-free multimodal anesthesia. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

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Background: Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery. Methods: This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and intercentre variation in critical care admission after emergency laparotomy. Results: Of 4529 patients included, 37.8% (n¼1713) underwent planned critical care admissions from theatre. Some 3.1% (n¼86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n¼133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51e19.97) than planned admissions (OR: 2.32, 95% CI: 1.43e3.85). Some 26.7% of patients (n¼1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8e51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n¼10/145) of centres outside the 95% CI. Conclusions: After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A free fibular flap is commonly used in adult mandibular reconstruction; however, its use in the pediatric population is not strongly supported. The authors are reporting the long-term update of a case of a pediatric patient who underwent a mandibular reconstruction using a free fibular flap after a resection of mandibular desmoid fibromatosis. Greatest growth was objectively measured and demonstrated at the condyle using a 3-dimensional model generated from Materialise software. This is 1 case and subsequent studies should be observed to further elucidate the full growth potential of the mandible in pediatric patients undergoing mandibular reconstruction.

Pain is a physiologic mechanism of the human body. Early cultures believed pain to have demonic and spiritual origins. In the early nineteenth century, morphine was first isolated by the German pharmacist Friedrich Wilhelm Adam Ferdinand Serturner. Since then, synthetic opioids and other derivatives of morphine have been developed for a wide variety of purposes, including pain relief during surgery. Opioids mainly act through the stimulation of μ-receptors, which has inhibitory effects on the propagation of pain signals to the brain. However, opioids also have unwanted side effects like nausea, vomiting, constipation, postoperative sedation, dizziness, and addiction, and are associated with significant morbidity, prolong hospital stays, increase use of medications needed to reverse side effects, and decrease patient satisfaction. Furthermore, use and abuse of opioids have contributed to an opioid epidemic, especially in the United States since the beginning of the twenty-first century. Opioid-free anesthesia is an alternative aimed at providing pain relief without the opioid-related adverse effects and to enhance recovery. Non-opioid alternatives and preoperative patient education strategies have been shown to be superior in the management of postoperative pain and opioid requirements. Clinicals have embraced these concepts enthusiastically and have begun to incorporate an opioid-free pain management approach in surgery.

As the world calls for expanded access to learning resources, e-learning may provide brick-and-mortar universities, an avenue to disseminate knowledge beyond the lecture halls. Online content for general surgery remains limited to a mixed bag of procedural videos of varying quality. To fill the gap for expert-curated content, the Department of Surgery and Transplantation at the University Hospital in Zurich, Switzerland published weekly video lectures on YouTube covering abdominal surgery curricula. Viewers flocked to these videos during the coronavirus disease 2019 pandemic. In response, the department took a survey among users with professional health care backgrounds both online and locally to evaluate the impact of these unique lectures.The videos were prepared by residents under the close supervision of specialized academic experts. The residents were given 3 weeks to prepare the presentations, which covered general and transplantation surgery. Each presentation was ~20 minutes, described standards in a structured way, critically appraised landmark studies, and defined the impact of those studies on the latest guidelines. Interactive questions were addressed to the residents in the audience and a moderating expert led the concluding discussion.Between 2017 and 2022, 120 video presentations were published on the YouTube channel and the videos were collectively viewed more than 619,000 times. Seven hundred eight health care professionals from 106 countries participated in the online survey, which revealed the main motivations for video consumption to be continuing medical education, examination preparation, and targeted search for answers to specific questions. The preferred contents included guidelines, latest research topics, presentation of complex conditions, descriptions of surgical procedures, and rare diseases. The features most appreciated were the quality of the lectures, free access to the content, noncommercial background, and well-selected topics. Of the respondents, 69% would have appreciated learning goals at the beginning and corresponding questions at the end.Between 2020 and 2021, a survey of local participants yielded 422 responses, with 94% reporting a positive learning experience. About half reported the most appreciated part was the quality and/or structure of the lecture. The experience could have been enhanced through more clinical research according to 46% of the audience, more discussion according to 25%, and more data and evidence according to 18%. 83% of the presenters reported satisfaction with their presentation. Most were also satisfied with the support provided by their advisor, with only 8% feeling more could have been done in terms of literature search and background knowledge support. Both presenters and advisors had positive feedback: the presenters learned a lot preparing the presentation and the advisors were able to teach colleagues.Experts predict that e-learning will become the didactic gold standard at many universities with the introduction of sophisticated educational...