Featured Articles in August 2020

Exploring the Impact of COVID-19 on Progress Towards Achieving Global Surgery Goals

 

Author list

Dennis Mazingi, Sergio Navarro, Matthew C. Bobel, Andile Dube, Chenesa Mbanje & Chris Lavy

 

Abstract

Introduction

In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low- and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis.

 

Methods

We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low- and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future.

 

Results

Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis.

 

Conclusions

If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low- and middle-income countries responsive to “old threats and new challenges”. Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.

 

URL-  https://rdcu.be/b46vQ


The Decreasing Incidence of Acute Appendicitis During COVID-19: A Retrospective Multi-centre Study

 

Author list

James Tankel, Aner Keinan, Ori Blich, Michael Koussa, Brigitte Helou, Shahaf Shay, Diaa Zugayar, Alon Pikarsky, Haggi Mazeh, Ram Spira & Petachia Reissman

 

Abstract

Background

As the novel coronavirus disease 19 (COVID-19) spreads, a decrease in the number of patients with acute appendicitis (AA) has been noted in our institutions. The aim of this study was to compare the incidence and severity of AA before and during the COVID-19 pandemic.

 

Methods

A retrospective cohort analysis was performed between December 2019 and April 2020 in the four high-volume centres that provide health care to the municipality of Jerusalem, Israel. Two groups were created. Group A consisted of patients who presented in the 7 weeks prior to COVID-19 first being diagnosed, whilst those in the 7 weeks after were allocated to Group B. A comparison was performed between the clinicopathological features of the patients in each group as was the changing incidence of AA.

 

Results

A total of 378 patients were identified, 237 in Group A and 141 in Group B (62.7% vs. 37.3%). Following the onset of COVID-19, the weekly incidence of AA decreased by 40.7% (p = 0.02). There was no significant difference between the groups in terms of the length of preoperative symptoms or surgery, need for postoperative peritoneal drainage or the distribution of complicated versus uncomplicated appendicitis.

 

Conclusions

The significant decrease in the number of patients admitted with AA during the onset of COVID-19 possibly represents successful resolution of mild appendicitis treated symptomatically by patients at home. Further research is needed to corroborate this assumption and identify those patients who may benefit from this treatment pathway.

 

URL-  https://rdcu.be/b46vV


Safety and Efficacy of Bedside Peritoneal Dialysis Catheter Placement in the COVID-19 Era: Initial Experience at a New York City Hospital

 

Author list

Mariana Vigiola Cruz, Omar Bellorin, Vesh Srivatana & Cheguevara Afaneh

 

Abstract

Introduction

Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is common in critically ill patients with COVID-19. Unparalleled numbers of patients with AKI and shortage of dialysis machines and operative resources prompted consideration of expanded use of urgent-start peritoneal dialysis (PD) and evaluation of the safety and efficacy of bedside surgical placement of PD catheters.

 

Study design

Bedside, open PD catheter insertions were performed in early April 2020, at a large academic center in New York City. Patients with SARS-CoV-2 infection and AKI and ambulatory patients with chronic kidney disease and impending need for RRT were included. Detailed surgical technique is described.

 

Results

Fourteen catheters were placed at the bedside over 2 weeks, 11 in critically ill COVID-19 patients and three in ambulatory patients. Mean patient age was 61.9 years (43–83), and mean body mass index was 27.1 (20–37.6); four patients had prior abdominal surgery. All catheters were placed successfully without routine radiographic studies or intraoperative complications. One patient (7%) experienced primary nonfunction of the catheter requiring HD. One patient had limited intraperitoneal bleeding while anticoagulated, which was managed by mechanical compression of the abdominal wall and temporarily holding anticoagulation. All other catheters had an adequate function at 3–18 days of follow-up.

 

Conclusions

Bedside placement of PD catheters is safe and effective in ICU and outpatient clinic settings. Our surgical protocols allowed for optimization of critical hospital resources, minimization of hazardous exposure to healthcare providers and a broader application of urgent-start PD in selected patients. Long-term follow-up is warranted.

 

URL-  https://rdcu.be/b46v4

 

 


Surgical Strategy During the COVID-19 Pandemic in a University Metropolitan Hospital in Milan, Italy

 

Author list

Nicolò M. Mariani, Andrea Pisani Ceretti, Veronica Fedele, Matteo Barabino, Vincenzo Nicastro, Marco Giovenzana, Giovanna Scifo, Enrico De Nicola & Enrico Opocher

 

Abstract

The COVID-19 pandemic has spread rapidly, forcing some drastic changes not only in our daily lives, but also in our clinical and surgical activities. Given our extensive Italian experience, we hereby describe how our surgical unit activity has changed and how, in some cases, it was necessary to modify surgical strategies. We hope our experience can be shared with our global colleagues who are suffering under similar condition.

 

URL-  https://rdcu.be/b46wb


Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patients: A Call for Global Consideration of Sampling all Asymptomatic Patients Before Surgical Treatment

 

Author list

Chen Nahshon, Arie Bitterman, Riad Haddad, David Hazzan & Ofer Lavie

 

Abstract

Background

In December 2019, a novel coronavirus was identified as the cause of many pneumonia cases in China and eventually declared as a pandemic as the virus spread globally. Few reports were published on the outcome of surgical procedures in diagnosed COVID-19 patients and even fewer on the surgical outcomes of asymptomatic undiagnosed COVID-19 surgical patients. We aimed to review all published data regarding surgical outcomes of preoperatively asymptomatic untested coronavirus disease 2019 (COVID-19) patients.

 

Methods

This report is a review on the perioperative period in COVID-19 patients who were preoperatively asymptomatic and not tested for COVID-19. Searches were conducted in PubMed April 4th, 2020. All publications, of any design, were considered for inclusion.

 

Results

Four reports were identified through our literature search, comprising 64 COVID-19 carriers, of them 51 were diagnosed only in the postoperative period. Synthesis of these reports, concerning the postoperative outcomes of patients diagnosed with COVID-19 during the perioperative period, suggested a 14/51 (27.5%) postoperative mortality rate and severe mostly pulmonic complications, as well as medical staff exposure and transmission.

 

Conclusions

COVID-19 may have potential hazardous implications on the perioperative course. Our review presents results of unacceptable mortality rate and a high rate of severe complications. These observations warrant further well-designed studies, yet we believe it is time for a global consideration of sampling all asymptomatic patients before surgical treatment.

 

URL-  https://rdcu.be/b46we


Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations

 

Author list

Mary E. Brindle, Caraline McDiarmid, Kristin Short, Kathleen Miller, Ali MacRobie, Jennifer Y. K. Lam, Megan Brockel, Mehul V. Raval, Alexandra Howlett, Kyong-Soon Lee, Martin Offringa, Kenneth Wong, David de Beer, Tomas Wester, Erik D. Skarsgard, Paul W. Wales, Annie Fecteau, Beth Haliburton, Susan M. Goobie & Gregg Nelson

 

Abstract

Background

Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery.

 

Methods

A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process.

 

Results

Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline.

 

Discussion

We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

 

URL-  https://rdcu.be/b46wp


Expectant Management of Patients with Ventral Hernias: 3 Years of Follow-up

 

Author list

Alexander C. Martin, Nicole B. Lyons, Karla Bernardi, Julie L. Holihan, Deepa V. Cherla, Juan R. Flores, Lillian Huang, Alexis Milton, Puja Shah, Lillian S. Kao, Tien C. Ko & Mike K. Liang

 

Abstract

Background

The safety and effectiveness of expectant management (e.g., watchful waiting or initially managing non-operatively) for patients with a ventral hernia is unknown. We report our 3-year results of a prospective cohort of patients with ventral hernias who underwent expectant management.

 

Methods

A hernia clinic at an academic safety-net hospital was used to recruit patients. Any patient undergoing expectant management with symptoms and high-risk comorbidities, as determined by a surgeon based on institutional criteria, would be included in the study. Patients unlikely to complete follow-up assessments were excluded from the study. Patient-reported outcomes were collected by phone and mailed surveys. A modified activities assessment scale normalized to a 1–100 scale was used to measure results. The rate of operative repair was the primary outcome, while secondary outcomes include rate of emergency room (ER) visits and both emergent and elective hernia repairs.

 

Results

Among 128 patients initially enrolled, 84 (65.6%) completed the follow-up at a median (interquartile range) of 34.1 (31, 36.2) months. Overall, 28 (33.3%) patients visited the ER at least once because of their hernia and 31 (36.9%) patients underwent operative management. Seven patients (8.3%) required emergent operative repair. There was no significant change in quality of life for those managed non-operatively; however, substantial improvements in quality of life were observed for patients who underwent operative management.

 

Conclusions

Expectant management is an effective strategy for patients with ventral hernias and significant comorbid medical conditions. Since the short-term risk of needing emergency hernia repair is moderate, there could be a safe period of time for preoperative optimization and risk-reduction for patients deemed high risk.

 

URL-  https://rdcu.be/b46wT


Safety of Major Abdominal Operations in the Elderly

 

Author list

Allison N. Martin, Darian L. Hoagland, Florence E. Turrentine, R. Scott Jones & Victor M. Zaydfudim

 

Abstract

Background

Preoperative assessment of geriatric-specific determinants of health may enhance perioperative risk stratification among elderly patients. This study examines effects of geriatric-specific variables on postoperative outcomes in patients undergoing elective major abdominal operations.

 

Methods

Patients included in the ACS NSQIP pilot Geriatric Surgery Research File program who underwent elective pancreatic, liver, and colorectal operations between 2014 and 2016 were examined. Multivariable analyses were performed to evaluate associations between patient-specific geriatric variables and risk of death, morbidity, readmission, and discharge destination.

 

Results

A total of 4165 patients were included. Patients ≥85 years were more likely to die, experience postoperative morbidity, and be discharged to a facility (all p ≤ 0.039) than younger patients. Preoperatively, patients ≥85 years were more likely to use a mobility aid, have a prior fall, have consent signed by a surrogate, and to live alone at home prior to operation (all p < 0.001). After adjustment for ACS NSQIP-estimated probabilities of morbidity or mortality, no geriatric-specific preoperative risk factors were significantly associated with increased risk of death or complications in any age group (all p > 0.055). Patients 75–84 and ≥85 years were more likely to be discharged to facility (OR 2.33 and 4.75, respectively, both p < 0.001) compared to patients 65–74 years. All geriatric-specific variables: use of mobility aid, living alone, consent signed by a surrogate, and fall history, were significantly associated with discharge to a facility (all p ≤ 0.001).

 

Conclusions

After adjusting for comorbid conditions, geriatric-specific variables are not associated with postoperative mortality and morbidity among elderly patients; however, geriatric-specific variables are significantly associated with discharge to a facility.

 

URL-  https://rdcu.be/b46wV

The Effects of Preferred Music on Laparoscopic Surgical Performance

 

Author list

Pim Oomens, Victor X. Fu, Vincent E. E. Kleinrensink, Gert-Jan Kleinrensink & Johannes Jeekel

 

Abstract

Introduction

Music can have a positive effect on stress and general task performance. This randomized crossover study assessed the effects of preferred music on laparoscopic surgical performance in a simulated setting.

 

Methods

Sixty medical students, inexperienced in laparoscopy, were included between June 2018 and November 2018. A randomized, 4-period, 4-sequence, 2-treatment crossover study design was used, with each participant acting as its own control. Participants performed four periods, consisting of five peg transfer tasks each period, on a laparoscopic box trainer: two periods while wearing active noise-cancelling headphones and two periods during music exposure. Participants were randomly allocated to a sequence determining the order of the four periods. The parameters time to task completion, path length and normalized jerk were assessed. Mental workload was assessed using the Surgical Task Load Index questionnaire. Also, heart rate and blood pressure were assessed.

 

Results

Participants performed the peg transfer task significantly faster [median difference: − 0.81 s (interquartile range, − 3.44–0.69) p = 0.037] and handled their instruments significantly more efficient as path length was reduced [median difference, − 52.24 mm (interquartile range, − 196.97–89.81) p = 0.019] when exposed to music. Also, mental workload was significantly reduced during music [median difference, − 2.41 (interquartile range, − 7.17–1.83) p = 0.021)]. No statistically significant effect was observed on heart rate and blood pressure.

 

Conclusion

Listening to preferred music improves laparoscopic surgical performance and reduces mental workload in a simulated setting.

 

URL-  https://rdcu.be/b46wZ

Acute Care Surgery Models Worldwide: A Systematic Review

 

Author list

Mats J. L. van der Wee, Gwendolyn van der Wilden & Rigo Hoencamp

 

Abstract

Background

The Acute Care Surgery (ACS) model was developed as a dedicated service for the provision of 24/7 nontrauma emergency surgical care. This systematic review investigated which components are essential in an ACS model and the state of implementation of ACS models worldwide.

 

Methods

A literature search was conducted using PubMed, MEDLINE, EMBASE, Cochrane library, and Web of Science databases. All relevant data of ACS models were extracted from included articles.

 

Results

The search identified 62 articles describing ACS models in 13 countries. The majority consist of a dedicated nontrauma emergency surgical service, with daytime on-site attending coverage (cleared from elective duties), and 24/7 in-house resident coverage. Emergency department coverage and operating room access varied widely. Critical care is fully embedded in the original US model as part of the acute care chain (ACC), but is still a separate unit in most other countries. While in most European countries, ACS is not a recognized specialty yet, there is a tendency toward more structured acute care.

 

Conclusions

Large national and international heterogeneity exists in the structure and components of the ACS model. Critical care is still a separate component in most systems, although it is an essential part of the ACC to provide the best pre-, intra- and postoperative care of the physiologically deranged patient. Universal acceptance of one global ACS model seems challenging; however, a global consensus on essential components would benefit any healthcare system.

 

URL-  https://rdcu.be/b46w1

 

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