Featured Articles in Aug 2018

Joint Statement by the Surgery Journal Editors Group

 

Author list: Nader K. Francis, Thomas Walker, Fiona Carter, Martin Hubner, Angela Balfour, Dorthe Hjort Jakobsen, Jennie Burch, Tracy Wasylak, Nicolas Demartines, Dileep N. Lobo, Valerie Addor, Olle Ljungqvist 

 

Abstract:

The Surgery Journal Editors Group is comprised of editors from 74 international, surgery-related journals who meet once a year at the annual meeting of the American College of Surgeons and discuss concerns common among surgery journals. The World Journal of Surgery editorial leadership is a member of this group and subscribes to the tenets expressed in the Joint Statement. Our instructions to authors will reflect these requirements and our editorial decisions will include their consideration.

 

URL: https://rdcu.be/19OB

 


Welcome New Associate Editor David Watson of Australia

 

Author list: Julie Ann Sosa

 

Abstract:

Professor Watson is Professor and Head of Surgery at Flinders University, and works concurrently as an esophagogastric surgeon at Flinders Medical Centre in Adelaide, South Australia. His interests include gastroesophageal reflux, and esophageal and gastric cancer. For more than 25 years, he has led clinical and laboratory research addressing benign and malignant esophageal disease, integrating laboratory, clinical and population research streams.

 

URL: https://rdcu.be/19OT

 


Post-operative Complications Following Emergency Operations Performed by Trainee Surgeons: A Retrospective Analysis of Surgical Deaths

 

Author list: Noha Ferrah, Karen Stephan, Janaka Lovell, Joseph Ibrahim, Barry Beiles

 

Abstract:

Background

Adequate surgical care of patients and concurrent training of residents is achieved in elective procedures through careful case selection and adequate supervision. Whether this applies when trainees are involved in emergency operations remains equivocal. The aim of this study was therefore to compare the risk of post-operative complications following emergency procedures performed by senior operators compared with supervised trainees.

 

Methods

This is a retrospective cohort study examining in-hospital deaths of patients across all surgical specialties who underwent emergency surgery in Australian public hospitals reported to the national surgical mortality audit between 2009 and 2015. Multivariable logistic regression was used to explore whether there was an association between the level of operator experience (senior operator vs trainee) and the occurrence of post-operative surgical complications following an emergency procedure.

 

 

Results

Our population consisted of 6920 patients. There were notable differences between the trainees and senior operator groups; trainees more often operated on patients aged over 80 years, with cardiovascular and neurological risk factors. Senior operators more often operated on very young and obese patients with advanced malignancy and hepatic disease. Supervised trainees had a lower rate of post-operative complications compared with senior operators; 18% (n = 396) and 25% (n = 1210), respectively (p < 0.05). Operations performed by trainees were associated with an 18% decrease (95% CI 5–29%; p < 0.05) in odds of post-operative complications compared with senior operators, adjusting for potential confounders.

 

Conclusion

Contrary to popular belief, our results suggest that supervised trainees safely perform emergency operations, provided that cases are judiciously selected.

 

URL: https://rdcu.be/19Pf

 


Effect of Time to Operation on Value of Care in Acute Care Surgery

 

Author list: Tyler J. Loftus, Martin D. Rosenthal, Chasen A. Croft, R. Stephen Smith, Philip A. Efron, Frederick A. Moore, Alicia M. Mohr, Scott C. Brakenbridge

 

Abstract:

Background

As reimbursement models evolve, there is increasing emphasis on maximizing value-based care for inpatient conditions. We hypothesized that longer intervals between admission and surgery would be associated with worse outcomes and increased costs for acute care surgery patients, and that these associations would be strongest among patients with high-risk conditions.

 

Methods

We performed a 5-year retrospective analysis of three risk cohorts: appendectomy (low-risk for morbidity and mortality, n = 618), urgent hernia repair (intermediate-risk, n = 80), and laparotomy for intra-abdominal sepsis with temporary abdominal closure (sTAC; high-risk, n = 102). Associations between the interval from admission to surgery and outcomes including infectious complications, mortality, length of stay, and hospital charges were assessed by regression modeling.

 

Results

Median intervals between admission and surgery for appendectomy, hernia repair, and sTAC were 9.3, 13.5, and 8.1 h, respectively, and did not significantly impact infectious complications or mortality. For appendectomy, each 1 h increase from admission to surgery was associated with increased hospital LOS by 1.1 h (p = 0.002) and increased intensive care unit (ICU) LOS by 0.3 h (p = 0.011). For hernia repair, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 1.6 h (p = 0.007), increased hospital LOS by 3.3 h (p = 0.002), increased ICU LOS by 1.5 h (p = 0.001), and increased hospital charges by $1918 (p < 0.001). For sTAC, each 1 h increase from admission to surgery was associated with increased antibiotic duration by 5.0 h (p = 0.006), increased hospital LOS by 3.9 h (p = 0.046), increased ICU LOS by 3.5 h (p = 0.040), and increased hospital charges by $3919 (p = 0.002).

 

Conclusions

Longer intervals from admission to surgery were associated with prolonged antibiotic administration, longer hospital and ICU length of stay, and increased hospital charges, with strongest effects among high-risk patients. To improve value of care for acute care surgery patients, operations should proceed as soon as resuscitation is complete.

 

URL: https://rdcu.be/19Py

 


Predictive Factors for Intestinal Transmural Necrosis in Patients with Acute Mesenteric Ischemia

 

Author list: Sameh Hany Emile

 

Abstract:

Background

Acute mesenteric ischemia (AMI) is a serious and potentially fatal condition. No definite parameter can predict transmural bowel necrosis in patients with AMI to justify early surgical intervention. The current study aimed to identify the clinical, laboratory, and radiologic parameters that can successfully predict the onset of intestinal transmural necrosis in patients with AMI.

 

Methods

Records of patients with AMI in the period of January 2013 to October 2017 were reviewed. Clinical parameters as patients’ symptoms, vital signs, and signs of peritonitis along with the results of laboratory and radiologic investigations were analyzed to identify predictive factors for intestinal transmural necrosis using binary logistic regression analysis.

 

Results

One hundred and one patients (70 males) with mean age of 55 years were included. Venous occlusion was the cause of AMI in 78 (77.3%) patients and arterial occlusion in 23 (22.7%) patients. Twenty-two patients completed conservative treatment successfully, whereas 79 patients required exploratory laparotomy. On laparotomy, six patients were found to have viable bowel. Overall, 28 patients had viable bowel and 73 had bowel necrosis. The significant independent predictors for transmural bowel necrosis were mesenteric arterial occlusion (OR: 26.5, p = 0.02), leukocytosis (OR: 1.3, p < 0.0001), acidosis (OR: 3.8, p = 0.04), free intraperitoneal fluid (OR: 4.21, p = 0.005), and combined portal vein and SMV thrombosis in CT scan (OR: 3.4, p = 0.026).

 

Conclusion

The independent predictors for transmural bowel necrosis were mesenteric arterial occlusion, leukocytosis, acidosis, free intraperitoneal fluid, and combined portal vein and SMV thrombosis in CT scan.

 

URL: https://rdcu.be/19P0

 


The Effect of Human-Immunodeficiency Virus Status on Outcomes in Penetrating Abdominal Trauma: An Interim Analysis

 

Author list: Deirdre McPherson, Valentin Neuhaus, Rohin Dhar, Sorin Edu, Andrew J. Nicol, Pradeep H. Navsaria

 

Abstract:

Background

The purpose of this study was to determine whether the outcomes of hemodynamically stable patients undergoing exploratory laparotomy for penetrating abdominal trauma differed as a result of their HIV status.

 

Methods

This was an observational, prospective study from February 2016 to May 2017. All hemodynamically stable patients with penetrating abdominal trauma requiring a laparotomy were included. The mechanism of injury, the HIV status, age, the penetrating abdominal trauma index (PATI), and the revised trauma score (RTS) were entered into a binary logistic regression model. Outcome parameters were in-hospital death, morbidity, admission to intensive care unit (ICU), relaparotomy within 30 days, and length of stay longer than 30 days.

 

Results

A total of 209 patients, 94% male, with a mean age of 29 ± 10 years were analysed. Twenty-eight patients (13%) were HIV positive. The two groups were comparable. Ten (4.8%) laparotomies were negative. There were two (0.96%) deaths, both in the HIV negative group. The complication rate was 34% (n = 72). Twenty-nine patients (14%) were admitted to the ICU. A higher PATI, older age, and a lower RTS were significant risk factors for ICU admission. After 30 days, 12 patients (5.7%) were still in hospital. Twenty-four patients (11%) underwent a second laparotomy. The PATI score was the single independent predictor for complications, relaparotomy, and hospital stay longer than 30 days.

 

Conclusions

Preliminary results reveal that HIV status does not influence outcomes in patients with penetrating abdominal trauma.

 

URL: https://rdcu.be/19XT

 


Wide Surgical Margin Improves the Outcome for Patients with Gastrointestinal Stromal Tumors (GISTs)

 

Author list: Jan Ahlen, Fredrik Karlsson, Johan Wejde, Inga-Lena Nilsson, Catharina Larsson, Robert Branstrom

 

Abstract:

Background

Surgical resection is still the main treatment for gastrointestinal stromal tumor (GIST), and R0 excision, regardless of surgical margins, is considered sufficient.

 

Methods

A cohort of 79 consecutive GIST cases treated at the Karolinska University Hospital, who were without metastasis at diagnosis and who had not received any pre-or postoperative treatment with tyrosine kinase inhibitors, was included. Surgical margins were evaluated at the time of surgery and classified as wide, marginal or intralesional. Time to local/peritoneal recurrence, distant metastasis, and survival were recorded. Cox regression analysis was used to investigate the association between surgical margin, and recurrence and survival.

 

Results

Local/peritoneal recurrence was diagnosed in 2/39 cases with wide margins, in 7/22 cases with marginal margins, and in 13/18 cases with intralesional surgery. Compared to wide margins this gives a hazard ratio of 6.8 (confidence interval 1.4–32.7) for marginal margins and 13.5 (3–61) for intralesional margins. In multivariate analysis, adjusting for size, site, and mitotic index, surgical margin remained an independent significant predictor of risk for recurrence. When classifying patients according to R0/R1 surgery, patients with R0 surgery showed longer time to peritoneal recurrence and better recurrence-free and disease-specific survival as compared to those with R1 resection. However, when excluding patients operated with wide surgical margin, no significant difference was observed.

 

Conclusions

Wide surgical margins are of significant prognostic importance, supporting the strategy of en bloc resection with good margin and careful handling of the tumor to avoid damaging the peritoneal surface in surgical resection of GIST.

 

URL: https://rdcu.be/19Yj

 


Excellent Prognosis of Central Lymph Node Recurrence-Free Survival for cN0M0 Papillary Thyroid Carcinoma Patients Who Underwent Routine Prophylactic Central Node Dissection

 

Author list: Yasuhiro Ito, Akira Miyauchi, Hiroo Masuoka, Mitsuhiro Fukushima, Minoru Kihara, Akihiro Miya

 

 Abstract:

Background

In Japan, prophylactic central node dissection (p-CND) for papillary thyroid carcinoma (PTC) has been routinely performed in many institutions, including ours (Kuma Hospital, Japan). We evaluated the recurrence to a central lymph node in patients with cN0M0 PTC who underwent routine p-CND.

 

Methods

We enrolled 4301 patients with cN0M0 PTC who underwent an initial surgery between 1987 and 2005 (median age 51 years). The postoperative follow-up periods ranged from 4 to 362 months (median 164 months). Only 15 patients underwent radioactive iodine (RAI) ablation (≥30 mCi) after total or near total thyroidectomy.

 

Results

Of the 4301 patients with N0M0 PTC who underwent p-CND, 2548 (59%) were diagnosed as pN1a on postoperative pathological examination. To date, only 52 cases (1.2%) showed recurrence to a central lymph node. The 10-year and 20-year central node recurrence-free survival rates were excellent at 99.1 and 98.2%, respectively. On multivariate analysis, age ≥55 years, significant extrathyroid extension, tumor size >2 cm, and ≥5 pathologically confirmed central node metastases (but not the presence of central node metastasis) independently affected central node recurrence.

 

Conclusions

Under the situation of routine p-CND, the central node recurrence-free survival of cN0M0 PTC is excellent. However, future studies, including double-arm studies from Japan, should examine whether the omission of p-CND cN0M0 PTC is appropriate without RAI ablation in consideration of various factors, including the pros and cons of p-CND.

 

URL: https://rdcu.be/19Y3

 

 

Neonatal Gastric Perforation: Case Series and Literature Review

 

Author list: Tianyou Yang, Yongbo Huang, Wei Zhong, Tianbao Tan, Jiakang Yu, Le Li, Jing Pan, Chao Hu, Jiliang Yang, Yan Zou

 

Abstract:

Background

We reported clinical findings of neonatal gastric perforation in a tertiary children’s hospital.

 

Methods

Retrospective chart reviews were conducted for neonatal gastric perforation between 1980 and 2016. Factors including sex, gestational age, birth weight, age, main symptoms and signs, white blood cell count (WBC), surgical intervention time (time between development of main symptom and surgical intervention), surgical findings, pathologic results, clinical outcomes, and causes of death were collected.

 

Results

Sixty-eight patients were identified. In total, 76.5% were male infants, the median age was 4 days, median birth weight was 2500 g, and 42.6% were premature. Abdominal distention and vomiting were the most common symptoms, and pneumoperitoneum was the most common radiographic finding. The median surgical intervention time was 51 h (range 8–312). In total, 73.5% of perforations occurred in the great curvature, 17.6% in the lesser curvature, and 8.9% unspecified. The median perforation size was 4 cm (range 0.2–16). Associated gastrointestinal anomalies were found in 20.6% of patients, and the most common anomaly was intestinal malrotation. Of the 51 patients with pathologic results, 11 showed the presence of musculature in the perforated gastric wall, while 40 showed the absence of musculature. Of the 66 patients with known clinical outcomes, 26 (39.4%) died, 23 of who died of infection. Among those aforementioned factors, WBC has a significant impact on survival. The mortality for four arbitrary divided year groups (1980–1989, 1990–1999, 2000–2009, and 2010–2016) was 100, 50, 31.6, and 16.7%, respectively.

Conclusions

The mortality of neonatal gastric perforation is constantly decreasing. Associated gastrointestinal anomalies and the presence of musculature are found in a minority of this condition.

 

URL: https://rdcu.be/19ZI

 

 

 

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