Featured Articles in Dec 2018

Symposium Celebrating Women Surgeons Around the World

 

Author list: Sanziana Roman, Maria Jimenez, Fualal Odubu, Nathalie Chereau, Doris Henne-Bruns, Cheng-Har Yip, Julie Howle, Marco G. Patti 

 

Abstract:

We must thank Dr. Sanziana Roman for organizing this symposium about women in surgery. Powerful testimonials from women surgeons, from Europe to the United States, from Africa to Australia and Asia. Each of them is different, as it reflects the culture of the place where their career took place. However, they all have in common the struggle to establish themselves in the surgical profession, traditionally a male-dominated field.

 

Over the last two decades, the situation has clearly improved. Today in most medical schools about 50% of the students are women, and a similar percentage is present in many surgical residency programs. Twenty-one Departments of Surgery in the United States are led by women, a major change as compared to only 5 years ago. Much more must be done to establish a work environment where women are as welcomed and respected as men; where they are accepted as surgeons, and not as women surgeons, treasuring the contribution they can give.

 

We do hope that this symposium will be inspirational for women and men in the surgical field and be enlightening and educational for all, promoting a culture of collegiality and mutual understanding. The glass ceiling has been cracked, it is now time to break it for good.

 

URL: https://rdcu.be/bajnY

 


Prospective Risk Factor Analysis for the Development of Post-operative Urinary Retention Following Ambulatory General Surgery

 

Author list: A. J. Scott, S. E. Mason, A. J. Langdon, B. Patel, E. Mayer, K. Moorthy, S. Purkayastha

 

Abstract:

Background

Post-operative urinary retention (POUR) is a common cause of unplanned admission following day-case surgery and has negative effects on both patient and surgical institution. We aimed to prospectively evaluate potential risk factors for the development of POUR following day-case general surgical procedures.

 

Methods

Over a 24-week period, consecutive adult patients undergoing elective day-case general surgery at a single institution were prospectively recruited. Data regarding urinary symptoms, comorbidities, drug history, surgery and perioperative anaesthetic drug use were collected. The primary outcome was the incidence of POUR, defined as an impairment of bladder voiding requiring either urethral catheterisation, unplanned overnight admission or both. Potential risk factors for the development of POUR were analysed by logistic regression.

 

Results

A total of 458 patients met the inclusion criteria during the study period, and data were collected on 382 (83%) patients (74.3% male). Sixteen patients (4.2%) experienced POUR. Unadjusted analysis demonstrated three significant risk factors for the development of POUR: age ≥ 56 years (OR 7.77 [2.18–27.78], p = 0.002), laparoscopic surgery (OR 3.37 [1.03–12.10], p = 0.044) and glycopyrrolate administration (OR 5.56 [2.00–15.46], p = 0.001). Male sex and lower urinary tract symptoms were not significant factors. Multivariate analysis combining type of surgery, age and glycopyrrolate use revealed that only age ≥ 56 years (OR 8.14 [2.18–30.32], p = 0.0018) and glycopyrrolate administration (OR 3.48 [1.08–11.24], p = 0.0370) were independently associated with POUR.

 

Conclusion

Patients aged at least 56 years and/or requiring glycopyrrolate—often administered during laparoscopic procedures—are at increased risk of POUR following ambulatory general surgery.

 

URL: https://rdcu.be/bajoh

 


Effects of Thoracic Epidural Anaesthesia on the Serosal Microcirculation of the Human Small Intestine

 

Author list: A. L. M. Tavy, A. F. J. de Bruin, K. van der Sloot, E. C. Boerma, C. Ince, P. G. Noordzij, D. Boerma, M. van Iterson

 

Abstract:

Background

The effect of thoracic epidural analgesia (TEA) on splanchnic blood flow during abdominal surgery remains unclear. The purpose of this study was to examine whether the hemodynamic effects of TEA resulted in microcirculatory alterations to the intestinal serosa, which was visualized using incident dark-field (IDF) videomicroscopy.

 

Methods

An observational cohort study was performed. In 18 patients, the microcirculation of the intestinal serosa was visualized with IDF. Microcirculatory and hemodynamic measurements were performed prior to (T1) and after administering a bolus of levobupivacaine (T2). If correction of blood pressure was indicated, a third measurement was performed (T3). The following microcirculatory parameters were calculated: microvascular flow index, proportion of perfused vessels, perfused vessel density and total vessel density. Data are presented as median [IQR].

 

Results

Mean arterial pressure decreased from 73 mmHg (68–83) at T1 to 63 mmHg (±11) at T2 (p = 0.001) with a systolic blood pressure of 114 mmHg (98–128) and 87 (81–97), respectively (p = 0.001). The microcirculatory parameters of the bowel serosa, however, were unaltered. In seven patients, blood pressure was corrected to baseline values from a MAP of 56 mmHg (55–57), while microcirculatory parameters remained constant.

 

Conclusion

We examined the effects of TEA on the intestinal serosal microcirculation during abdominal surgery using IDF imaging for the first time in patients. Regardless of a marked decrease in hemodynamics, microcirculatory parameters of the bowel serosa were not significantly affected.

 

URL: https://rdcu.be/bajoH

 


Impact of Micrometastatic Axillary Nodes on Survival of Breast Cancer Patients with Tumors ≤2 cm

 

Author list: Hyeon Woo Bae, Kwang Hyun Yoon, Joo Heung Kim, Sung Mook Lim, Jee Ye Kim, Hyung Seok Park, Seho Park, Seung Il Kim, Young Up Cho, Byeong-Woo Park

 

Abstract:

Background

This study investigated the impact of pN1mi disease on the survival of T1 breast cancer patients and examined the clinical usefulness of the online PREDICT tool and updated staging system.

Methods

The node stages of 2344 patients were divided into pN0, pN1mi, and pN1a. Clinicopathological parameters and survival outcomes were retrospectively analyzed. Data for 111 micrometastatic diseases were applied to the PREDICT version 2.0 and re-classified using the 8th edition of the cancer staging manual.

 

Results

Univariable analyses demonstrated worse disease-free and overall survival rates for patients with node-positive cancer; however, the significance was not maintained in multivariable analyses. Chemotherapy improved outcomes in patients with node-positive and non-luminal A-like subtype cancers. The PREDICT tool demonstrated good performance when estimating the 5-year overall survival for pN1mi disease (area under the receiver operating characteristic curve, 0.834). According to the updated staging system, 74% of cases were down-staged to IA, and clearly splitting survival curves were identified.

 

Conclusions

pN1mi disease alone did not adversely affect survival outcomes. Biologic and treatment factors determined outcomes in cases of small-volume node micrometastasis. The PREDICT tool or new staging classification could help predict the survival of patients with micrometastatic sentinel nodes.

 

URL: https://rdcu.be/bajo3

 


Robotic Reoperative Anti-reflux Surgery: Low Perioperative Morbidity and High Symptom Resolution

 

Author list: Adham Elmously, Katherine D. Gray, Timothy M. Ullmann, Thomas J. Fahey III, Cheguevara Afaneh, Rasa Zarnegar

 

Abstract:

Background

Laparoscopic reoperative anti-reflux surgery (ARS) has a significantly higher morbidity than laparoscopic primary ARS; however, it is not known whether the same pattern exists within the robotic approach. We aimed to evaluate the safety and efficacy of robotic reoperative ARS in comparison with primary robotic ARS.

 

Methods

A retrospective review of patients undergoing primary or reoperative robotic ARS at a tertiary referral center between 2012 and 2017 was performed. Perioperative outcomes and long-term symptom resolution were evaluated.

 

Results

A total of 200 patients were included (38 reoperative and 162 primary ARS). Baseline characteristics were comparable across groups. Seven (18.4%) of the reoperative patients had two or more prior foregut operations. Patients in the reoperative group had a longer operative time (226 vs. 180 min, p < 0.001). There were no conversions to open technique, and one patient in the reoperative group (2.6%) had an intraoperative perforation. Twenty of the 38 reoperative patients (52.6%) were discharged within 24 h as compared to 109/162 primary patients (64.9%) (p = 0.09). The readmission rate and postoperative complication rates were 6 and 3%, respectively, and did not differ between groups. At a mean follow-up of 1 year, complete or partial resolution of preoperative symptoms was achieved in 97% of primary patients and 100% of reoperative patients (p = 0.4).

 

Conclusion

The robotic approach allows for minimal morbidity, short length of stay, and excellent functional outcomes in patients undergoing reoperative ARS when compared to patients undergoing primary ARS.

 

URL: https://rdcu.be/bajo9

 


Magnetic Anastomosis for Biliojejunostomy: First Prospective Clinical Trial

 

Author list: Xue-Min Liu, Xiao-Peng Yan, Hong-Ke Zhang, Feng Ma, Yan-Guang Guo, Chao Fan, Shan-Pei Wang, Ai-Hua Shi, Bo Wang, Hao-Hua Wang, Jian-Hui Li, Xiao-Gang Zhang, Rongqian Wu, Xu-Feng Zhang, Yi Lv

 

Abstract:

Background

Magnetic compression anastomosis (magnamosis, MCA) has been verified safe and effective by us and others in animal bilioenteric anastomosis (BEA). The objective of the present study was to introduce clinical application of magnetic compression bilioenteric anastomosis (MC-BEA) with a unique device in series of patients.

 

Methods

Patients with obstructive jaundice with an indication of BEA were prospectively enrolled from 2012 to 2015. After dissection of bile ducts, the mother ring and drainage tube were placed in the proximal bile duct and the purse-string suture was tightened over the drainage tube. The drainage tube was introduced into the jejunal lumen at the anastomotic site and used to guide the daughter ring to assemble with the mother ring. All the patients were routinely followed up for magnets discharge or any complications associated.

 

Results

Forty-one patients were included. Thirty-four (82.9%) patients had a malignant primary disease, while seven (17.1%) had benign disease. The median time for MC-BEA was 10.5 min (interquartile range [IQR] 8.3–13.0 min). No perioperative morbidity or mortality associated with MC-BEA was observed. The median time for a patent bilioenteric anastomosis formation was 19.0 days (IQR 14.5–23.0 days), and the magnets were discharged with a median postoperative duration of 35.0 days (IQR 28.0–43.0 days). With a median follow-up of 547.5 days (range 223–1042 days), no patients had biliary fistula, while two (4.9%) developed anastomotic stricture at 4 months and 14 months after surgery, and underwent reoperation for reconstruction of BEA.

 

Conclusions

MCA is a safe, effective, and time-saving modality for biliojejunostomy.

 

URL: https://rdcu.be/bajpH

 


Discrimination, Bullying and Harassment in Surgery: A Systematic Review and Meta-analysis

 

Author list: Yeqian Huang, Terence C. Chua, Robyn P. M. Shaw, Christopher J. Young

 

Abstract:

Background

In 2015, the public media in Australia reported a series of life stories of victims who had been subjected to inappropriate behaviors in their surgical careers, bringing the profession into disrepute. Currently, limited data are available in the medical literature on discrimination, bullying and harassment (DBH) in surgery. This significant information gap prompted a systematic review to compile relevant information about DBH in surgical practice and training, in particular, its prevalence and impact.

 

Methods

A literature search was conducted using the MEDLINE, EMBASE and PubMed databases (May 1929–October 2017). Studies identified were appraised with standard selection criteria. Data points were extracted, and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

 

Results

Eight studies, comprising 5934 participants, were examined. Discrimination occurred in a pooled estimate of 22.4% [95% Confidence Interval (CI) = 14.0–33.9%]. One of the papers reported the prevalence of bullying using two methods including Revised Negative Acts Questionnaire and a definition by Einarsen. Pooled estimate of incidence rate was thus 37.7% (95% CI = 34.0–41.5%) and 40.3% (95% CI = 34.7–46.2%), respectively. In terms of harassment, pooled prevalence was 31.2% (95% CI = 10.0–65.0%).

 

Conclusions

DBH is a significant issue in surgery. The true incidence of these issues may remain underestimated. Actions are being taken by professional bodies to create a positive culture in surgery. The effectiveness of these strategies is yet to be determined. More studies are warranted to investigate the magnitude of these issues given their psychological impact, and more importantly to monitor the effectiveness of current measures.

 

URL: https://rdcu.be/bajpT

 

 

 


 

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