To Stent or Not to Stent… What is the Best Management of an Esophageal Leak or Benign Perforation?
Author list - Sarah K. Thompson & David I. Watson
URL – https://rdcu.be/b1RTq
Laparoscopic Trans-Abdominal Retromuscular (TARM) Repair for Ventral Hernia
Author list - Ashwin A. Masurkar
The complications of intraperitoneal onlay mesh repair for ventral hernia has favored sublay mesh placement like open Rives–Stoppa repair (ORS). There was a need for low-cost laparoscopic trans-abdominal repair using a polypropylene mesh (PPM) with sublay, midline closure and addition of posterior component separation (PCS) by transversus abdominis release (TAR).
The techniques used three or six operating ports with triangulation. After adhesiolysis, a transverse incision was made on the peritoneum (P) and posterior rectus sheath (PRS). The retromuscular space was developed by raising a P-PRS flap. Midline closure was performed with No. 1 polydioxanone, and a PPM was placed in sublay, followed by closure of defect and P-PRS incision. For large hernias with divarication; myo-fascial medialization using PCS-TAR aided low-tension midline closure.
Eighty-nine patients were operated from 2010 to 2019, 26 primary ventral; 63 incisional; and 22 recurrent hernias. Of the primary, 21 were umbilical, one Spigelian and four epigastric hernias. The incisional group had 57 patients with lower midline scars (C-section 25, open tubal ligation 15, abdominal hysterectomy 17), five lateral (appendicectomy), one post-laparotomy. The mean age, male/female sex ratio and BMI were 41.23 years, 1:10.1 and 29.2 kg/m2, respectively. Mean defect and mesh area were 110 cm2 and 392 cm2. Mean operating time was 192 min. Conversion to open, mesh infection and recurrence rates were 3.4%, 1.1% and 5.62%.
Laparoscopic TARM with PPM in sublay avoids mesh–bowel contact. It provides midline closure and PCS-TAR within the same port geometry with results comparable with ORS.
URL – https://rdcu.be/b1RTF
Definitions for Loss of Domain: An International Delphi Consensus of Expert Surgeons
Author list - Samuel G. Parker, Steve Halligan, Mike K. Liang, Filip E. Muysoms, Gina L. Adrales, Adam Boutall, Andrew C. de Beaux, Ulrich A. Dietz, Celia M. Divino, Mary T. Hawn, Todd B. Heniford, Joon P. Hong, Nabeel Ibrahim, Kamal M. F. Itani, Lars N. Jorgensen, Agneta Montgomery, Salvador Morales-Conde, Yohann Renard, David L. Sanders, Neil J. Smart, Jared J. Torkington & Alastair C. J. Windsor
No standardized written or volumetric definition exists for ‘loss of domain’ (LOD). This limits the utility of LOD as a morphological descriptor and as a predictor of peri- and postoperative outcomes. Consequently, our aim was to establish definitions for LOD via consensus of expert abdominal wall surgeons.
A Delphi study involving 20 internationally recognized abdominal wall reconstruction (AWR) surgeons was performed. Four written and two volumetric definitions of LOD were identified via systematic review. Panelists completed a questionnaire that suggested these definitions as standardized definitions of LOD. Consensus on a preferred term was pre-defined as achieved when selected by ≥80% of panelists. Terms scoring <20% were removed.
Voting commenced August 2018 and was completed in January 2019. Written definition: During Round 1, two definitions were removed and seven new definitions were suggested, leaving nine definitions for consideration. For Round 2, panelists were asked to select all appealing definitions. Thereafter, common concepts were identified during analysis, from which the facilitators advanced a new written definition. This received 100% agreement in Round 3. Volumetric definition: Initially, panelists were evenly split, but consensus for the Sabbagh method was achieved. Panelists could not reach consensus regarding a threshold LOD value that would preclude surgery.
Consensus for written and volumetric definitions of LOD was achieved from 20 internationally recognized AWR surgeons. Adoption of these definitions will help standardize the use of LOD for both clinical and academic activities.
URL – https://rdcu.be/b1RT5
The Significance of Histologically “Large Normal” Parathyroid Glands in Primary Hyperparathyroidism
Author list - Russel Krawitz, Anthony Glover, Sireesha Koneru, James Jiang, Aimee Di Marco, Anthony J. Gill, Ahmad Aniss, Mark Sywak, Leigh Delbridge & Stan Sidhu
We investigated outcomes in a cohort of patients with a biochemical diagnosis of primary hyperparathyroidism (pHPT) undergoing surgery for asymptomatic disease or target organ damage, where a focussed or four-gland operation was undertaken and the histopathology only reported a “large normal” parathyroid gland (LNP).
Methods and materials
Patients subjected to a parathyroidectomy for pHPT between 2012 and 2018 with a pathology of LNP were included. Patients with fat depletion or additional histological features of adenoma or hyperplasia in any of the resected glands were excluded. A control group was formed from 50 consecutive patients with the histological finding of adenoma or hyperplasia during the same study period. The primary outcome was biochemical normalisation of pHPT at 1–2 weeks and after 6 months post-operatively.
Forty-eight LNP patients (2% of all parathyroidectomies) were included in the study group with 50 matched controls. LNP patients had a lower biochemical cure rate (81% vs. 98% P < 0.05) and a higher risk of recurrence (10% vs. 0%, P = 0.06). LNP patients had a milder form of pHPT (Ca2+ 2.63 vs. 2.68 P < 0.05) with a smaller PTH and Ca2+ drop post-operatively. For LNP patients with failure, a definite additional cause of pHPT was found in only two patients.
This study highlights a controversial area in pHPT and reports LNP as a cause of pHPT. The biochemical analysis of this LNP group supports a benefit in resection in the setting of pHPT, although the risk of failure (persistence/recurrence) is higher than those with adenoma or hyperplasia. Stricter post-operative follow-up of LNP patients should be considered.
URL – https://rdcu.be/b1RUF
The Scale-Up of the Global Surgical Workforce: Can Estimates be Achieved by 2030?
Author list - Kimberly M. Daniels, Johanna N. Riesel, Stéphane Verguet, John G. Meara & Mark G. Shrime
The Lancet Commission on Global Surgery showed that countries with surgeon, anesthetist, and obstetrician (SAO) densities of 20–40 SAO/100,000 population were associated with improved health outcomes and recommended a global surgical workforce scale-up by 2030. Whether countries would be able to achieve such scale-up efforts in that time-frame is unknown.
A differential equation model was used to estimate the growth rate and number of SAO necessary for each country to reach the aforementioned SAO densities. Workforce data from Mexico and India were used to estimate achievable rates of SAO scale-up for middle- and low-income countries, respectively. Secular surgical growth rates were estimated to demonstrate what might occur without dedicated scale-up efforts.
To reach at least 20 SAO/100,000 population in all countries by 2030, over 808 thousand SAO need to be trained by 2030. To reach at least 40 SAO/100,000 population, over 2.1 million SAO need to be trained. If countries adopt a scale-up rate similar to Mexico’s previously achieved rate of scale-up, 66% of countries would have 20 SAO/100,000 population by 2030. If countries adopt a scale-up rate similar to India’s previously achieved rate of scale-up, 56% would have 20 SAO/100,000 population by 2030.
With dedicated efforts in surgical workforce scale-up, significant gains in SAO density can be made worldwide. However, without intervention, many countries are unlikely to improve their current workforce densities. Investments in workforce scale-up are likely to yield workforce gains that mirror current resource states.
URL – https://rdcu.be/b1RVu
Magnetic Spiderman, a New Surgical Training Device
Author list - Yue Wang, Huan Chen, Bo Tang, Tao Ma, Qingshan Li, Haoyang Zhu, Xiaogang Zhang, Yi Lv & Dinghui Dong
Difficulties with liver transplantation (LT)-related surgical techniques are great challenges for young surgeons. Thus, young surgeons need to undergo systematic preclinical training. However, an optimal training system for LT is still lacking. This study aims to evaluate the safety and educational value of the Magnetic Spiderman (MS) during LT-related surgical techniques training, particularly during training for the preparation of the donor’s liver and vascular reconstruction.
For the donor liver preparation training, the pulling force of the MS was measured using 16 porcine livers. Another 40 porcine livers were divided into two groups: MS group (used MS in the preparation of the liver) (n = 25) and manual group (took manual assistance in the preparation of the liver) (MA group, n = 15). In vascular reconstruction training, 25 pairs of porcine iliac veins were used to practice reconstruction. Five LT experts evaluated the MS for its use in LT-related surgical techniques training.
During the donor liver preparation training, the number of assistants required in the MS group was significantly less than the number required in the MA group (0 vs. 1.8 ± 0.1; P < 0.001). However, the number of vasculature leaking points was similar between the two groups (0.2 ± 0.1 vs. 0.4 ± 0.2; P = 0.51). In vascular reconstruction training, the trainee alone could complete the vascular reconstruction training, with a reconstruction success rate of 80% (20/25). All five experts considered the MS a viable alternative to assistants, with the ability to facilitate single surgeon training for LT. Four out of five (80%) experts considered MS quite safe for surgery and effective at keeping the surgical field clear.
MS can reduce the number of assistants to zero in LT-related techniques training without increasing the risk of the operation, thus facilitating training for LT.
URL – https://rdcu.be/b1RVP
Critical Appraisal of the Impact of Oesophageal Stents in the Management of Oesophageal Anastomotic Leaks and Benign Oesophageal Perforations
Author list - Sivesh K. Kamarajah, James Bundred, Gary Spence, Andrew Kennedy, Bobby V. M. Dasari & Ewen A. Griffiths
Endoscopic placement of oesophageal stents may be used in benign oesophageal perforation and oesophageal anastomotic leakage to control sepsis and reduce mortality and morbidity by avoiding thoracotomy. This updated systematic review aimed to assess the safety and effectiveness of oesophageal stents in these two scenarios.
A systematic literature search of all published studies reporting use of metallic and plastic stents in the management of post-operative anastomotic leaks, spontaneous and iatrogenic oesophageal perforations were identified. Primary outcomes were technical (deploying ≥ 1 stent to occlude site of leakage with no evidence of leakage of contrast within 24–48 h) and clinical success (complete healing of perforation or leakage by placement of single or multiple stents irrespective of whether the stent was left in situ or was removed). Secondary outcomes were stent migration, perforation and erosion, and mortality rates. Subgroup analysis was performed for plastic versus metallic stents and anastomotic leaks versus perforations separately.
A total of 66 studies (n = 1752 patients) were included. Technical and clinical success rates were 96% and 87%, respectively. Plastic stents had significantly higher migration rates (24% vs 16%, p = 0.001) and repositioning (11% vs 3%, p < 0.001) and lower technical success (91% vs 95%, p = 0.032) than metallic stents. In patients with anastomotic leaks, plastic stents were associated with higher stent migration (26% vs 15%, p = 0.034), perforation (2% vs 0%, p = 0.013), repositioning (10% vs 0%, p < 0.001), and lower technical success (95% vs 100%, p = p = 0.002). In patients with perforations only, plastic stents were associated with significantly lower technical success (85% vs 99%, p < 0.001).
Covered metallic oesophageal stents appear to be more effective than plastic stents in the management of oesophageal perforation and anastomotic leakage. However, quality of evidence of generally poor and high-quality randomised trial is needed to further evaluate best management option for oesophageal perforation and anastomotic leakage.
URL – https://rdcu.be/b1RVV