Featured Articles in Apr 2021

Damage Control Surgery may be a Safe Option for Severe Non-Trauma Peritonitis Management

 

 

Authors:

Carlos A. Ordoñez, Michael Parra, Alberto García, Fernando Rodríguez, Yaset Caicedo, José Julián Serna, Alexander Salcedo, Josefa Franco, Luis Eduardo Toro, Juliana Ordoñez, Luis Fernando Pino, Mónica Guzmán, Claudia Orlas, Juan Pablo Herrera, Gonzalo Aristizábal, Francesco Pata & Salomone Di Saverio

Abstract:

Background

Damage control surgery (DCS) has emerged as a new option in the management of non-traumatic peritonitis patients to increase survival in critically ill patients. The purpose of this study was to compare DCS with conventional strategy (anastomosis/ostomies in the index laparotomy) for severe non-traumatic peritonitis regarding postoperative complications, ostomy rate, and mortality and to propose a useful algorithm in the clinical practice.

Methods

Patients who underwent an urgent laparotomy for non-trauma peritonitis at a single level I trauma center in Colombia between January 2003 and December 2018, were retrospectively included. We compared patients who had DCS management versus definitive initial surgical management (DISM) group. We evaluated clinical outcomes and morbidities among groups.

Results

290 patients were included; 81 patients were treated with DCS and 209 patients underwent DISM. Patients treated with DCS had a worse critical status before surgery with higher SOFA score [median, DCS group: 5 (IQR: 3–8) vs. DISM group: 3 (IQR: 1–6), p < 0.001]. The length of hospital stay and overall mortality rate of DCS group were not significant statistical differences with DISM group. Complications rate related to primary anastomosis or primary ostomy was similar. There is not difference in ostomy rate among groups. At multivariate analysis, SOFA > 6 points and APACHE-II > 20 points correlated with a higher probability of DCS.

Conclusion

DCS in severe non-trauma peritonitis patients is feasible and safe as surgical strategy management without increasing mortality, length hospital of stay, or complications. DCS principles might be applied in the non-trauma scenarios without increase the stoma rate.

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Survival After Adrenalectomy for Metastatic Hepatocellular Carcinoma

 

 

Authors:

JI. Staubitz, M. Hoppe-Lotichius, J. Baumgart, J. Mittler, H. Lang & TJ. Musholt

Abstract:

Background

Extrahepatic manifestation of hepatocellular carcinoma (HCC) is rare and primarily affects lung, lymph nodes and bone. Metastases to the adrenal glands are relatively infrequent. This 25-year institutional experience aimed for an analysis of factors influencing survival in patients undergoing surgery for HCC adrenal metastasis.

Methods

A retrospective analysis of the institutional database of the Clinic for General-, Visceral- and Transplantation Surgery of the University Medical Center Mainz, Germany, was performed. Patients who underwent surgery for HCC adrenal metastases from January 1995 to June 2020 were included. Pre-, peri- and postoperative factors with potential influence on survival were assessed.

Results

In 16 patients (14 males, two females), one bilateral and 15 unilateral adrenalectomies were performed (13 metachronous, three synchronous). Thirteen operations were carried out via laparotomy, and three adrenalectomies were minimally invasive (two laparoscopic, one retroperitoneoscopic). Median overall survival (after HCC diagnosis) was 35 months, range: 5–198. Median post-resection survival (after adrenalectomy) was 15 months, range: 0–75. Overall survival was longer in patients with the primary HCC treatment being liver transplantation (median 66 months) or liver resection (median 51 months), compared to only palliative intended treatment of the primary with chemotherapy (median 35 months) or local ablation (median 23 months).

Conclusions

Surgery is a feasible treatment option for patients with adrenal metastases originating from HCC. In patients who underwent adrenalectomy for HCC adrenal metastasis, overall survival was superior, if primary HCC treatment was potentially curative (liver transplantation or resection).

Open Access: https://link.springer.com/article/10.1007/s00268-020-05909-0

 

 


Active Breaks Initiative During Hospital Rounds in the Surgical ICU to Improve Wellness of Healthcare Providers

Authors:

Maria Armas, Danielle Aronowitz, Richard Gaona, Gene Coppa & Rafael Barrera

Abstract:

Background

Healthcare professionals in the intensive care unit (ICU) confront stressful working conditions. Morning rounds involve several hours of prolonged standing and uninterrupted concentration each day and require both mental and physical endurance from the entire care team. There is concern that work-related fatigue among ICU practitioners will compromise their ability to safely and effectively care for their patients. To address this concern, the surgical intensive care unit (SICU) at Long Island Jewish Medical Center implemented an initiative to promote provider wellness through “active breaks” during rounds.

Materials and methods

Between October and December 2019, 30 physicians, physician assistants, nurses, and students collectively engaged in active breaks during SICU rounds and then completed a 7-question, post-test survey to assess their experience. The survey consisted of both closed-end and open-ended questions. The data were then analyzed using simple statistics.

Results

In response to closed-ended questioning, the majority of participants agreed that active breaks relieved stress (27/30; 90%), promoted wellness (29/30; 96.7%), and improved team morale (29/30; 93.1%). When given the options of tricep dips, squats or push-ups, squats were the favored activity during breaks (17/30; 56.7%). Most of the participants (27/30; 90%) considered the active breaks to be appropriate for the working environment; two participants had no opinion on this matter. Approximately 90% of the respondents were interested in maintaining active breaks as part of the routine of morning rounds.

Conclusions

Our assessment suggests active breaks during rounds are a healthy outlet to address the inherent stress associated with critical care. This initiative also potentially protects healthcare providers from burnout and, consequentially, improves the quality of patient care.

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Role of Chewing Gum in Reducing Postoperative Ileus after Reversal of Ileostomy

 

 

Authors:

Samiullah Bhatti, Yusra Jahangir Malik, Shabbar Hussain Changazi, Usman Ali Rahman, Awais Amjad Malik, Usman Ismat Butt, Muhammad Umar, Muhammad Waris Farooka & Mahmood Ayyaz

Abstract:

Background

Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay.

Patients and methods

This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test.

Results

Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000).

Conclusion

It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

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ERAS: Expert Consensus of Data Elements for Collection for Enhanced Recovery After Cardiac Surgery

 

Authors:

Sameer A. Hirji, Rawn Salenger, Edward M. Boyle, Judson Williams, V. Seenu Reddy, Michael C. Grant, Subhasis Chatterjee, Alexander J. Gregory, Rakesh Arora & Daniel T. Engelman

Abstract:

Methods

A 2-round modified Delphi technique was utilized based on existing recommendations from the recently published ERAS® cardiac surgery consensus guidelines. Round 1 included a steering committee of 10 experts who oversaw formulation of a focused list of data elements into 3 main areas: Preoperative, intraoperative and postoperative. Round 2 consisted of a multidisciplinary, multinational, heterogenous group of 50 voting experts from across the United States and Europe. All participants evaluated their level of agreement with each data element using a 5-point Likert scale with consensus threshold of 70%.

Results

In round 1, 17 data elements were considered essential (consensus >  = 70%, either positive or negative) and 6 were considered marginal (consensus <  = 70%, either positive or negative). In round 2, positive consensus was achieved for 15/17 (88.2%) data elements in the essential category, and all six data elements (100%) in the marginal category, indicating a high level of overall agreement.

Conclusion

This initial study, which identified 21 key data elements for collection in an ERAS® cardiac program, will aid clinicians in establishing a framework for evaluating the quality of their contemporary ERP processes and will allow acquisition of data to help benchmark performance metrics between hospitals.

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Studying Enhanced Recovery After Surgery (ERAS®) Core Items in Colorectal Surgery

 

 

Authors:

Marco Gemma, Fulvia Pennoni & Marco Braga

Abstract:

Method

A causal latent variable model is proposed to analyze data obtained prospectively concerning 1261 patients undergoing elective colorectal surgery within the ERAS protocol. Primary outcomes (composite of any complication, surgical site infection, medical complications, early ready for discharge (TRD), early actual discharge) and secondary outcomes (composite of late bowel function recovery, IV fluid resumption, nasogastric tube replacement, postoperative nausea and vomiting, re-intervention, re-admission, death) are considered along with their multiple dimensions.

Results

Concerning the primary outcomes, our results evidence three subpopulations of patients: one with probable good outcome, one with possibly prolonged TRD and discharge without complications, and the other one with probable complications and prolonged TRD and discharge. Epidural anesthesia, waiving surgical drainage, and early ambulation, IV fluid stop and urinary catheter removal act favorably, while preoperative hospital stay and blood transfusion act negatively. Concerning the secondary outcomes our results evidence two subpopulations of patients: one with high probability of good outcome and one with high probability of complications. Epidural anesthesia, waiving surgical drainage, early ambulation and IV fluid stop act favorably, while blood transfusion acts negatively also with respect to these secondary outcomes.

Conclusion

The multivariate causal latent class two-parameter logistic model, a modern statistical method overcoming drawbacks of traditional models to estimate the average causal effects on the treated, allows us to disentangle subpopulations of patients and to evaluate ERAS interventions.

SharedIt Link: https://rdcu.be/cfiXR

 


My First Paper: Prognostic Factors in Curative Resected Locoregional Small Intestine Neuroendocrine Neoplasms

 

Authors:

Maximilian Evers, Anja Rinke, Johannes Rütz, Annette Ramaswamy, Elisabeth Maurer & Detlef K. Bartsch

Abstract:

Background

Small intestinal neuroendocrine neoplasms (SI-NEN) are rare, and only about 40% of patients are diagnosed without distant metastases. Aim of the study was to identify prognostic factors in patients with potentially curative resected locoregional SI-NEN.

Methods

Patients with curative resected locoregional SI-NEN (ENETS stages I-III) were retrieved from a prospective data base. Demographic, surgical and pathological data of patients with and without disease recurrence were retrospectively analyzed using univariate and multivariate analysis.

Results

In a 20-year period, 65 of 203 (32%) patients with SI-NEN were operated for stages I–III disease. Thirty-eight (58.5%) patients were men, and the median age at surgery was 59 (range 37–87) years. After median follow-up of 65 months, 14 patients experienced disease relapse median 28.5 (range 6–122) months after initial surgery, of which 2 died due to their disease. Multivariate analysis revealed age ≥ 60 years (HR = 6.41, 95% CI 1.38–29.67, p = 0.017), tumor size ≥ 2 cm (HR = 26.54, 95% CI 4.46–157.62, p < 0.001), lymph node ratio > 0.5 (HR 7.18, 95% CI 1.74–29.74, p = 0.007) and multifocal tumor growth (HR = 6.98, 95% CI 1.66–29.39, p = 0.008) as independent negative prognostic factors and right hemicolectomy compared to segmental small bowel resection (HR = 0.04, 95% CI 0.01–0.24, p < 0.001) as independent protector against recurrence.

Conclusion

Patients with locoregional SI-NEN with an age ≥ 60 years, tumor size ≥ 2 cm, lymph node ratio > 0.5 and multiple small bowel tumor foci have an increased risk for recurrence and might benefit from adjuvant treatment. In contrast, right hemicolectomy of ileal SI-NEN seems to reduce the risk of recurrence.

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Analysing the Operative Experience of Paediatric Surgical Trainees in Sub-Saharan Africa Using a Web-Based Logbook

 

 

Authors:

Ciaran Mooney, Sean Tierney, Eric O’Flynn, Miliard Derbew & Eric Borgstein

Abstract:

Background

The expansion of local training programmes is crucial to address the shortages of specialist paediatric surgeons across Sub-Saharan Africa. This study assesses whether the current training programme for paediatric surgery at the College of Surgeons of East, Central and Southern Africa (COSECSA) is exposing trainees to adequate numbers and types of surgical procedures, as defined by local and international guidelines.

Methods

Using data from the COSECSA web-based logbook, we retrospectively analysed numbers and types of operations carried out by paediatric surgical trainees at each stage of training between 2015 and 2019, comparing results with indicative case numbers from regional (COSECSA) and international (Joint Commission on Surgical Training) guidelines.

Results

A total of 7,616 paediatric surgical operations were recorded by 15 trainees, at different stages of training, working across five countries in Sub-Saharan Africa. Each trainee recorded a median number of 456 operations (range 56–1111), with operative experience increasing between the first and final year of training. The most commonly recorded operation was inguinal hernia (n = 1051, 13.8%). Trainees performed the majority (n = 5607, 73.6%) of operations recorded in the eLogbook themselves, assisting in the remainder. Trainees exceeded both local and international recommended case numbers for general surgical procedures, with little exposure to sub-specialities.

Conclusions

Trainees obtain a wide experience in common and general paediatric surgical procedures, the number of which increases during training. Post-certification may be required for those who wish to sub-specialise. The data from the logbook are useful in identifying individuals who may require additional experience and centres which should be offering increased levels of supervised surgical exposure.

Open Access: https://link.springer.com/article/10.1007/s00268-020-05892-6

 


Systematic Reviews and Meta-Analyses: Sentinel Lymph Node Biopsy in Gastric Cancer, an Optimization of Imaging Protocol for Tracer Mapping

Authors:

Yuqiang Huang, Mengting Pan & Bo Chen

Abstract:

Background

Sentinel lymph node biopsy (SLNB) plays an essential role in the evaluation of lymph node (LN) metastasis status and the extent of LN dissection in gastric cancer. The aim of our study was to perform a systematic review and meta-analysis for corresponding identification rate and sensitivity of different SLNB techniques.

Methods

Systematic search using PubMed, Embase, and Cochrane library databases was conducted for studies on SLNB in patients with gastric cancer. Studies were stratified according to the sentinel lymph node (SLN) biopsy technique: blue dye (BD), radiocolloid tracer (RI), indocyanine green (ICG), a combination of radiocolloid with blue dye (RI + BD), and a combination of radiocolloid with ICG (RI + ICG). A random-effect model was used to pool the identification rate, sensitivity, and accuracy.

Results

A total of 54 eligible studies (3767 patients) was included. The pooled identification rates of SLNB using BD, RI, ICG, RI + BD, RI + ICG were 95% (95%CI: 92–97%), 95% (95%CI: 93–97%), 99% (95%CI: 97–99%), 97% (95%CI: 96–98%), and 95% (95%CI: 87–99%), respectively. The pooled sensitivities were 82% (95%CI: 77–86%), 87% (95%CI: 81–92%), 90% (95%CI: 82–95%), 89% (95%CI: 84–93%), and 88% (95%CI: 79–94%), respectively. The pooled accuracies were 94% (95%CI: 91–96%), 95% (95%CI: 92–97%), 98% (95%CI: 95–99%), 97% (95%CI: 95–99%), and 98% (95%CI: 95–99%), respectively.

Conclusions

The current meta-analysis provides reliable evidence that favors the use of ICG and dual tracer method (RI + BD/ICG) for the identification of the SLN. Considering the high costs and potential biohazard of using radioactive substances in dual tracer method, performing SLNB with ICG is the technique of choice for experienced surgeons.

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Clinical Outcomes and Effectiveness of Laser Treatment for Hemorrhoids

Authors:

Kasun Lakmal, Oshan Basnayake, Umesh Jayarajah & Dharmabandhu N. Samarasekera

Abstract:

Background

Laser treatment is increasingly used in the treatment of symptomatic hemorrhoids, and several studies have attempted to describe its clinical outcomes. In this systematic review, we aimed to comprehensively analyze the clinical outcomes and effectiveness of laser treatment.

Methods

We performed a systematic review of currently available data on laser treatment for hemorrhoids. We searched MEDLINE and Google Scholar between January 2009 and May 2020. Studies that described the clinical outcomes and effectiveness of laser treatment were selected based on pre-specified inclusion criteria with a minimum follow-up period of 3 months. Qualitative synthesis of the clinical outcomes, effectiveness and complications was performed.

Results

Nineteen studies including 1937 patients were analyzed. The majority were males (n = 1239) and included grade 2 and 3 hemorrhoids. In the majority (n = 1750, 90.34%), the 980 nm wave length diode laser was used as the energy source. Doppler-guided localization was performed in six studies (n = 579, 29.89%). All studies (n = 1937) reported low postoperative pain scores and nine studies (n = 1131) showed significantly lower pain compared to open technique. Furthermore, six studies (n = 1023) showed significantly less intra- and postoperative bleeding compared to open technique. Seven studies (n = 1052) reported long-term follow-up results and were found to be satisfactory in terms of symptom relief and recurrence. This study was limited by heterogeneity of outcomes precluding a meta-analysis.

Conclusion

Laser treatment had acceptable clinical outcomes for grade 2 and 3 hemorrhoids with lower rates of postoperative pain and bleeding with satisfactory long-term outcomes.

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Minimally Invasive Pancreaticoduodenectomy in Elderly Patients

Authors:

Jisheng Zhu, Guiyan Wang, Peng Du, Jianpeng He & Yong Li

Abstract:

Background

Minimally invasive pancreaticoduodenectomy (MIPD) for pancreatic head or periampullary lesions is being utilized with increasing frequency. However, few data are available for the elderly. The objective of this study is to assess the safety and feasibility of MIPD in elderly population, by making a comparison with conventional open pancreaticoduodenectomy (OPD) and with non-elderly population.

Methods

We conducted a systematic search to identify all eligible studies in Cochrane Library, Ovid, and PubMed from their inception up to April 2020.

Results

Seven retrospective studies involving 2727 patients were included. Of these, 3 compared MIPD and OPD in elderly patients, 2 compared MIPD in elderly and non-elderly patients, and 2 included both outcomes. Compared to those with OPD, elderly patients who underwent MIPD were associated with less 90-day mortality (OR 0.56, 95% CI 0.32–0.97; P = 0.04) and fewer delayed gastric emptying (OR 0.54, 95% CI 0.33–0.88; P = 0.01). On the other hand, no significant difference was observed in terms of 30-day mortality, major morbidity, postoperative pancreatic fistula (grade B/C), postoperative hemorrhage, reoperation, 30-day readmission, and operative time. For patients who have treated with MIPD, elderly did not reveal worse outcomes than non-elderly.

Conclusion

MIPD is a safe and feasible procedure for select elderly patients if performed by experienced surgeons from high-volume pancreatic surgery centers. However, further randomized studies are required to confirm this.

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