Featured Articles in Aug 2022

In this issue:


Inspirational Women in Surgery: Professor Vijayalakshmi Deshmane, India

 

Author list:  Mallika Tewari & Savio George Barreto

 

FREE LINK  https://rdcu.be/cQ843

 

 


Editorial


We Asked the Experts: Repair Techniques as Prevention: Ostomy Closure is an Incisional Hernia Repair

 

Author list:  

Matthew Z. Wilson

 

FREE LINK  https://rdcu.be/cQ847


COVID-19: Advanced-Stage Melanoma at Presentation Following the Peak of the Pandemic

 

Author list:

Ryan Lamm, Walker Lyons, Winnie So & Alliric I. Willis

 

Background

For melanoma patients, timely identification and tumor thickness are directly correlated with outcomes. COVID-19 impacted both patients’ ability and desire to see physicians. We sought to identify whether the pandemic correlated with changes in melanoma thickness at presentation and subsequent treatment timeline.

Methods

Retrospective chart review was performed on patients who underwent surgery for melanoma in an academic center surgical oncology practice from May 2019 to September 2021. Patients were split into two cohorts: “pre-pandemic” from May 2019 to May 2020 and “pandemic,” after May 2020, representing when these patients received their initial diagnostic biopsy. Demographic and melanoma-specific variables were recorded and analyzed.

 

Results

A total of 112 patients were identified: 51 patients from the “pre-pandemic” and 61 from the “pandemic” time period. The pandemic cohort more frequently presented with lesions greater than 1 mm thickness compared to pre-pandemic (68.8% v 49%, p = 0.033) and were found to have significantly more advanced T stage (p = 0.02) and overall stage disease (p = 0.022). Additionally, trends show that for pandemic patients more time passed from patient-reported lesion appearance/change to diagnostic biopsy (5.7 ± 2.0 v 7.1 ± 1.5 months, p = 0.581), but less time from biopsy to operation (42.9 ± 2.4 v 52.9 ± 5.0 days, p = 0.06).

 

Conclusions

“Pandemic” patients presented with thicker melanoma lesions and more advanced-stage disease. These results may portend a dangerous trend toward later stage at presentation, for melanoma and other cancers with rapid growth patterns, that will emerge as the prolonged effects of the pandemic continue to impact patients’ presentation for medical care.

 

FREE LINK -https://rdcu.be/cQ86M

 


ERAS: Guidelines for Perioperative Care in Elective Abdominal and Pelvic Surgery in Low-Middle-Income Countries

 

Author list: 

Ravi Oodit, Bruce M. Biccard, Eugenio Panieri, Adrian O. Alvarez, Marianna R. S. Sioson, Salome Maswime, Viju Thomas, Hyla-Louise Kluyts, Carol J. Peden, Hans D. de Boer, Mary Brindle, Nader K. Francis, Gregg Nelson, Ulf O. Gustafsson & Olle Ljungqvist

 

Background

This is the first Enhanced Recovery After Surgery (ERAS®) Society guideline for primary and secondary hospitals in low–middle-income countries (LMIC’s) for elective abdominal and gynecologic care.

 

Methods

The ERAS LMIC Guidelines group was established by the ERAS® Society in collaboration with different representatives of perioperative care from LMIC’s. The group consisted of seven members from the ERAS® Society and eight members from LMIC’s. An updated systematic literature search and evaluation of evidence from previous ERAS® guidelines was performed by the leading authors of the Colorectal (2018) and Gynecologic (2019) surgery guidelines (Gustafsson et al in World J Surg 43:6592–695, Nelson et al in Int J Gynecol Cancer 29(4):651–668). Meta-analyses randomized controlled trials (RCTs), prospective and retrospective cohort studies from both HIC’s and LMIC’s were considered for each perioperative item. The members in the LMIC group then applied the current evidence and adapted the recommendations for each intervention as well as identifying possible new items relevant to LMIC’s. The Grading of Recommendations, Assessment, Development and Evaluation system (GRADE) methodology was used to determine the quality of the published evidence. The strength of the recommendations was based on importance of the problem, quality of evidence, balance between desirable and undesirable effects, acceptability to key stakeholders, cost of implementation and specifically the feasibility of implementing in LMIC’s and determined through discussions and consensus.

 

Results

In addition to previously described ERAS® Society interventions, the following items were included, revised or discussed: the Surgical Safety Checklist (SSC), preoperative routine human immunodeficiency virus (HIV) testing in countries with a high prevalence of HIV/AIDS (CD4 and viral load for those patients that are HIV positive), delirium screening and prevention, COVID 19 screening, VTE prophylaxis, immuno-nutrition, prehabilitation, minimally invasive surgery (MIS) and a standardized postoperative monitoring guideline.

 

Conclusions

These guidelines are seen as a starting point to address the urgent need to improve perioperative care and to effect data-driven, evidence-based care in LMIC’s.

 

 

FREE LINK https://rdcu.be/cQ87b

 


Suture or Mesh Repair of the Smallest Umbilical Hernias

 

Author list: 

Nadia A. Henriksen, Kristian Kiim Jensen, Thue Bisgaard, Frederik Helgstrand on behalf of the Danish Hernia Database

 

Background

Mesh is recommended for umbilical hernias with defects > 1 cm to reduce recurrence. For umbilical hernias with defect width ≤ 1 cm, the literature is sparse. The aim of this nationwide cohort study was to assess outcomes after suture and mesh repair of umbilical hernias with defect width ≤ 1 cm and to evaluate outcomes after onlay mesh repair specifically.

 

Methods

By merging data from the Danish Hernia Database and the National Patients Registry from 2007 to 2018, patients undergoing elective open repair of an umbilical hernia with defect width ≤ 1 cm were identified. Available data included details about comorbidity, surgical technique, 90-day readmission, 90-day reoperation and operation for recurrence.

 

Results

A total of 7849 patients were included, of whom 25.7% (2013/7849) underwent mesh repair. Reoperation for recurrence was significantly decreased after mesh repair 3.1% (95% C.I. 2.1–4.1) compared with suture repair 6.7% (95% C.I. 6.0–7.4), P < 0.001. Readmission and reoperation rates were significantly higher for mesh repair 7.9% (159/2013) and 2.6% (52/2013) than for suture repair 6.5% (381/5836) and 1.5% (89/5836), P = 0.036 and P = 0.002, respectively. Onlay mesh repairs had the lowest risk of recurrence 2.0% (95% C.I. 0.6–3.5), and readmission [7.9% (65/826)] and reoperation [3.9% (32/826)] rates within 90 days were comparable to suture repairs [6.5% (381/5836)] and [3.3% (192/5836)], P = 0.149 and P = 0.382, respectively.

 

Conclusions

Even for the smallest umbilical hernias, mesh repair significantly decreased the recurrence rate. Onlay mesh repair was associated with lowest risk of recurrence without increasing early complications.

 

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Perioperative Anxiety is Associated with Postoperative Complications in Vascular Surgery

 

 

Author list: 

Ksenija Jovanovic, Nevena Kalezic, Sandra Sipetic Grujicic, Vladan Zivaljevic, Milan Jovanovic, Biljana Kukic, Ranko Trailovic, Petar Zlatanovic, Perica Mutavdzic, Ivan Tomic, Nikola Ilic & Lazar Davidovic

 

Background

Preoperative anxiety is associated with increased morbidity and/or mortality in surgical patients. This study investigated the incidence, predictors, and association of preoperative anxiety with postoperative complications in vascular surgery.

 

Methods

Consecutive patients undergoing aortic, carotid, and peripheral artery surgery, under general and regional anesthesia, from February until October 2019 were included in a cross-sectional study. Anesthesiologists assessed preoperative anxiety using a validated Serbian version of the Amsterdam Preoperative Anxiety and Information Scale. Patients were divided into groups with low/high anxiety, both anesthesia- and surgery-related. Statistical analysis included multivariate linear logistic regression and point-biserial correlation.

 

Results

Of 402 patients interviewed, 16 were excluded and one patient refused to participate (response rate 99.7%). Out of 385 patients included (age range 39–86 years), 62.3% had previous surgery. High-level anesthesia- and surgery-related anxieties were present in 31.2 and 43.4% of patients, respectively. Independent predictors of high-level anesthesia-related anxiety were having no children (OR = 0.443, 95% CI: 0.239–0.821, p = 0.01), personal bad experiences with anesthesia (OR = 2.294, 95% CI: 1.043–5.045, p = 0.039), and time since diagnosis for ≥ 4 months (OR = 1.634, 95% CI: 1.023–5.983, p = 0.04). The female sex independently predicted high-level surgery-related preoperative anxiety (OR = 2.387, 95% CI: 1.432–3.979, p = 0.001). High-level anesthesia-related anxiety correlated with postoperative mental disorders (rpb = 0.193, p = 0.001) and pulmonary complications (rpb = 0.104, p = 0.042). Postoperative nausea (rpb = 0.111, p = 0.03) and postoperative mental disorders (rpb = 0.160, p = 0.002) correlated with high-level surgery-related preoperative anxiety.

 

Conclusions

Since preoperative anxiety affects the postoperative course and almost every third patient experiences anxiety preoperatively, routine screening might be recommended in vascular surgery.

 

FREE LINK - https://rdcu.be/cQ870

 


Prevalence and Predictors of Suicidal Ideation in Patients Following Cardiac Surgery

 

Author list:  

Krzysztof Jarmoszewicz, Mariusz Topolski, Adam Hajduk, Dorota Banaszkiewicz & Katarzyna Nowicka-Sauer

 

Background

Patient-reported outcomes (PROs) which demand special attention and immediate help are referred to as PROs alert. Suicidal ideation (SI) is one of the PROs alerts which are insufficiently investigated. The aim was to assess the prevalence and risk factors for SI in patients following cardiac surgery.

 

Methods

A total of 190 patients (mean age: 66.09, SD = 10.19; 57 women) were assessed at three months following cardiac surgery. SI was identified using the Patient Health Qustionnaire-9 (PHQ-9) question. The Hospital Anxiety and Depression Scale-Modified was used to assess anxiety, depression, and irritability. Additionally, self-perceived health improvement and level of hope were assessed using the Likert scale. Dyspnea and chest pain were assessed using a visual analogue scale.

 

Results

SI was observed in 14.7% of participants. Patients experiencing SI had significantly higher levels of depression, anxiety, irritability, dyspnea and chest pain. They perceived the surgery to be less effective and had lower levels of hope. No significant relationships were found regarding age, sex, employment status, myocardial infarction, heart failure, operation mode, type of procedure, extracorporal circulation, hospital stay and postsurgical complications. Logistic regression revealed female sex (B = 2.363), higher anxiety level (B = 0.451) and older age (B = 0.062) to be risk factors for SI. The total variance explained by the model was 46%.

 

Conclusions

Assessing suicidality and negative emotions with special emphasis on anxiety simultaneously with somatic complaints is vital to address PROs alerts and improve care for patients following cardiac surgery. In-depth evaluation and psychological care are recommended in case of positive screening.

FREE LINK  https://rdcu.be/cQ88K

 


Systematic Reviews and Meta-Analyses:


Open Versus Laparoscopic Surgical Management of Rectus Diastasis: Complications and Recurrence Rates

 

Author list: 

Hassan ElHawary, Christian Chartier, Peter Alam & Jeffrey E. Janis

 

 

Background

Rectus diastasis (RD) is defined as widening of the linea alba and laxity of the abdominal muscles. It can be treated via a wide array of both conservative and surgical modalities. Due to the quickly evolving nature of this field coupled with the multiple novel surgical modalities described recently, there is a need for an updated review of surgical techniques and a quantitative analysis of complications and recurrence rates.

 

Methods

A systematic review of PUBMED and EMBASE databases was preformed to retrieve all clinical studies describing surgical management of RD. Pooled analyses were preformed to assess recurrence and complication rates after both open and laparoscopic RD repairs (after controlling for herniorrhaphy).

 

Results

A total of 56 papers were included in this review. In patients who underwent both an RD and a herniorrhaphy, there was no significant difference in recurrence rates between open (0.86%) and laparoscopic repairs (1.6%) (p > 0.05). Similarly, in patients who underwent RD repair without a herniorrhaphy, there was no significant difference in recurrence rates between open (0.89%) and laparoscopic repairs (0%) (p > 0.05). The most common complications reported were seroma, skin dehiscence, hematoma/post-operative bleeding, and infection. After controlling for a herniorrhaphy, there were no significant difference in total complication rates between open and laparoscopic RD repair. The total complication rates in patients who underwent an open RD repair with a herniorrhaphy were 13.3% compared to 14.5% in patients who underwent laparoscopic repairs (p > 0.05). Similarly, the total complication rates in patients who underwent RD repair without a herniorrhaphy were 11.8% in patients who underwent open repairs compared to 16.2% in their counterparts who underwent laparoscopic repairs (p > 0.05).

 

Conclusion

Both open and laparoscopic approaches are safe and effective in repairing RD in patients with and without concurrent herniorrhaphy. Future research should report patient reported outcomes to better differentiate between different surgical approaches.

 

FREE LINK  https://rdcu.be/cQ88U

 


Telemedicine in Surgical Care in Low- and Middle-Income Countries

 

 

Author list: 

Eyitayo Omolara Owolabi, Tamlyn Mac Quene, Johnelize Louw, Justine I. Davies & Kathryn M. Chu

 

Background

Access to timely and quality surgical care is limited in low- and middle-income countries (LMICs). Telemedicine, defined as the remote provision of health care using information, communication and telecommunication platforms have the potential to address some of the barriers to surgical care. However, synthesis of evidence on telemedicine use in surgical care in LMICs is lacking.

 

Aim

To describe the current state of evidence on the use and distribution of telemedicine for surgical care in LMICs.

 

Methods

This was a scoping review of published and relevant grey literature on telemedicine use for surgical care in LMICs, following the PRISMA extension for scoping reviews guideline. PubMed-Medline, Web of Science, Scopus and African Journals Online databases were searched using a comprehensive search strategy from 1 January 2010 to 28 February 2021.

 

Results

A total of 178 articles from 53 (38.7%) LMICs across 11 surgical specialties were included. The number of published articles increased from 2 in 2010 to 44 in 2020. The highest number of studies was from the World Health Organization Western Pacific region (n = 73; 41.0%) and of these, most were from China (n = 69; 94.5%). The most common telemedicine platforms used were telephone call (n = 71, 39.9%), video chat (n = 42, 23.6%) and WhatsApp/WeChat (n = 31, 17.4%). Telemedicine was mostly used for post-operative follow-up (n = 71, 39.9%), patient education (n = 32, 18.0%), provider training (n = 28, 15.7%) and provider-provider consultation (n = 16, 9.0%). Less than a third (n = 51, 29.1%) of the studies used a randomised controlled trial design, and only 23 (12.9%) reported effects on clinical outcomes.

 

Conclusion

Telemedicine use for surgical care is emerging in LMICs, especially for post-operative visits. Basic platforms such as telephone calls and 2-way texting were successfully used for post-operative follow-up and education. In addition, file sharing and video chatting options were added when a physical assessment was required. Telephone calls and 2-way texting platforms should be leveraged to reduce loss to follow-up of surgical patients in LMICs and their use for pre-operative visits should be further explored. Despite these telemedicine potentials, there remains an uneven adoption across several LMICs. Also, up to two-thirds of the studies were of low-to-moderate quality with only a few focusing on clinical effectiveness. There is a need to further adopt, develop, and validate telemedicine use for surgical care in LMICs, particularly its impact on clinical outcomes.

 

 

FREE LINK https://rdcu.be/cQ89t

 


Using a Reinforced Stapler Decreases the Incidence of Postoperative Pancreatic Fistula after Distal Pancreatectomy

 

 

Author list:

Hani Oweira, Alessandro Mazotta, Arianeb Mehrabi, Christoph Reissfelder, Nuh Rahbari, Alexander Betzler, Hazem Elhadedy, Olivier Soubrane & Mohamed Ali Chaouch

 

Background

There is no consensus on the pancreatic transection during distal pancreatectomy (DP) to reduce postoperative pancreatic fistula (POPF). This meta-analysis aimed to evaluate the effects of a reinforced stapler on the postoperative outcomes of DP.

 

Methods

We systematically searched electronic databases and bibliographic reference lists in The PubMed/MEDLINE, Google Scholar, Cochrane Library's Controlled Trials Registry and Database of Systematic Reviews, Embase, and Scopus. Review Manager Software was used for pooled estimates.

 

Results

Seven eligible studies published between 2007 and 2021 were included with 553 patients (267 patients in the reinforced stapler group and 286 patients in the standard stapler group). The reinforced stapler reduced the POPF grade B and C (OR = 0.33; 95% CI [0.19, 0.57], p < 0.01). There was no difference between the reinforced stapler group and standard stapler group in terms of mortality rate (OR = 0.39; 95% CI [0.04, 3.57], p = 0.40), postoperative haemorrhage (OR = 0.53; 95% CI [0.20, 1.43], p = 0.21), and reoperation rate (OR = 0.91; 95% CI [0.40, 2.06], p = 0.82).

 

Conclusions

Reinforced stapling in DP is safe and seems to reduce POPF grade B/C with similar mortality rates, postoperative bleeding, and reoperation rate. The protocol of this systematic review with meta-analysis was registered in PROSPERO (ID: CRD42021286849).

 

FREE LINK https://rdcu.be/cQ89Z

 


 

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