LAUSR

To the Editor: We have read with great interest the study by O’Donnell et al, where the authors have tried to evaluate the so-called weekend effect in patients undergoing carotid endarterectomy. However, some points need to be addressed. First, the authors found that stroke/death risk was higher in asymptomatic patients or patients with stroke treated during the weekend, although patients treated for transient ischemic attack were not associated with a higher risk. This paradox should be discussed and probably investigated by the authors. It is clear that asymptomatic patients underwent an elective procedure even though they were operated on a weekend. Probable causes for this increased complications’ risk include the fatigue of the surgical team at the end of the week, the lower level of postoperative care, as well as the fact that the on-call anesthesiologists may not be familiar with the specific type of procedure usually conducted during working days. However, in a recent study, Cheng et al evaluated an older time period of the same database and they found that asymptomatic patients treated with carotid endarterectomy on Friday had the same risk for complications as patients operated during the rest of the week. What could be the cause for this recent increase in perioperative stroke/death risk during the last days of the week? Furthermore, both studies found an increased length of stay associated with procedures conducted at the end of the week. This could be justified by a lower level of postsurgical care during the weekends that could be associated with a smaller staff number or looser postoperative monitoring protocols. As we have underlined recently, postsurgical monitoring protocols are essential in patients undergoing carotid endarterectomy to prevent arterial pressure fluctuations and to avoid cerebral hyperperfusion. Moreover, longer hospital stay is associated with a higher risk for postoperative delirium, especially in older patients. In conclusion, if it is difficult to improve the level of care during the weekends because of financial reasons, perhaps it would be more prudent to stratify elective cases to schedule procedures of higher risk for the first days of the week.