Featured Articles in Dec 2020

Port Site Hernias Following Laparoscopic Ventral Hernia Repair

 

Author list:
Dhanani, N.H., Bernardi, K., Olavarria, O.A. et al.

Abstract:
Background

Port site hernias (PSH) are underreported following laparoscopic ventral hernia repair (LVHR). Most occur at the site of laterally placed 10–12-mm ports used to introduce large pieces of mesh. One alternative is to place the large port through the ventral hernia defect; however, there is potential for increased risk of surgical site infection (SSI). This study evaluates the outcomes when introducing mesh through a 10–12-mm port placed through the hernia defect.

Methods

This was a retrospective case series of patients who underwent LVHR in three prospective trials from 2014–2017 at one institution. All patients had mesh introduced through a 10–12-mm port placed through the ventral hernia defect. The primary outcome was SSI. Secondary outcomes were hernia occurrences including recurrences and PSH.

Results

A total of 315 eligible patients underwent LVHR with a median (range) follow-up of 21 (11–41) months. Many patients were obese (66.9%), recently quit tobacco use (8.8%), or had diabetes (18.9%). Most patients had an incisional hernia (61.2%), and 19.2% were recurrent. Hernias were on average 4.8 ± 3.8 cm in width. Two patients (0.6%) had an SSI. Fourteen patients had a hernia occurrence—13 (4.4%) had a recurrent hernia, and one patient (0.3%) had a PSH.

Conclusion

During LVHR, introduction of mesh through a 10–12-mm port placed through the hernia defect is associated with a low risk of SSI and low risk of hernia occurrence. While further studies are needed to confirm these results, mesh can be safely introduced through a port through the defect.

URL: https://rdcu.be/b8TqY

 


Endoscopic versus Conventional Thyroid Surgery: A Comparison of Quality of Life, Cosmetic Outcomes and Overall Patient Satisfaction with Treatment

 

Author list:
Johri, G., Chand, G., Mishra, A. et al.

Abstract:
Background

Our aim was to investigate whether the surgical approach, i.e. endoscopic (ET) versus conventional/open thyroidectomy (ConT), contributes towards the improvement in quality of life (QoL), cosmetic outcomes and overall patient satisfaction with treatment.

Methods

We conducted a prospective study (October 2016–August 2018) consisting of patients undergoing hemithyroidectomy for euthyroid, non-malignant solitary thyroid nodules (STNs). Patients were divided into two groups: Group I (ET)—41 patients and Group II (ConT)—52 patients. ET was performed via bilateral-axillo breast approach (BABA). A thyroid disease-specific questionnaire “ThyPRO-39hin” was used to evaluate pre- and post-operative QoL. Visual analogue scale (VAS) was used for post-operative pain. Cosmetic satisfaction, paraesthesia and overall satisfaction with treatment were evaluated using Likert-type verbal response scales. Pre- and post-operative scores (>6 months) were compared, and p value < 0.05 was considered significant.

Results

Mean age (p = 0.26), gender distribution (p = 0.07), mean tumour size (p = 0.74) and preoperative scores of QoL were comparable between the two groups. Post-operatively scores of symptom domain (p = 0.03), tiredness (p = 0.03), impaired social life (p = 0.03), cosmetic complaints (p =  < 0.001) and overall QoL (p =  < 0.001) were significantly better in Group I. Also, post-operative pain perception at first follow-up visit (p = 0.001) was lower in patients undergoing ET/Group I, with higher scar satisfaction scores (p =  < 0.001) and overall satisfaction with treatment (p =  < 0.001). Post-operative paraesthesia perception was comparable (p = 0.06) amongst the two groups.

Conclusion

In this cohort study, patients undergoing endoscopic thyroid surgery reported superior post-operative QoL, cosmetic and overall satisfaction with treatment as compared to conventional/open thyroidectomy.

URL: https://rdcu.be/b8TrR

 


Preoperative Risk Assessment: A Poor Predictor of Outcome in Critically ill Elderly with Sepsis After Abdominal Surgery

 

 

Author list:
Cuijpers, A.C.M., Coolsen, M.M.E., Schnabel, R.M. et al.

Abstract:
Background

Postoperative outcome prediction in elderly is based on preoperative physical status but its predictive value is uncertain. The goal was to evaluate the value of risk assessment performed perioperatively in predicting outcome in case of admission to an intensive care unit (ICU).

Methods

A total of 108 postsurgical patients were retrospectively selected from a prospectively recorded database of 144 elderly septic patients (>70 years) admitted to the ICU department after elective or emergency abdominal surgery between 2012 and 2017. Perioperative risk assessment scores including Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality (P-POSSUM) and American Society of Anaesthesiologists Physical Status classification (ASA) were determined. Acute Physiology and Chronic Health Evaluation IV (APACHE IV) was obtained at ICU admission.

Results

In-hospital mortality was 48.9% in elderly requiring ICU admission after elective surgery (n = 45), compared to 49.2% after emergency surgery (n = 63). APACHE IV significantly predicted in-hospital mortality after complicated elective surgery [area under the curve 0.935 (p < 0.001)] where outpatient ASA physical status and P-POSSUM did not. In contrast, P-POSSUM and APACHE IV significantly predicted in-hospital mortality when based on current physical state in elderly requiring emergency surgery (AUC 0.769 (p = 0.002) and 0.736 (p = 0.006), respectively).

Conclusions

Perioperative risk assessment reflecting premorbid physical status of elderly loses its value when complications occur requiring unplanned ICU admission. Risks in elderly should be re-assessed based on current clinical condition prior to ICU admission, because outcome prediction is more reliable then.

URL: https://rdcu.be/b8Tr0

 


My First Paper: A Last Resort When There is No Blood: Experiences and Perceptions of Intraoperative Autotransfusion Among Doctors in Resource-Limited Settings

 

Author list:
Sjöholm, A., Älgå, A. & von Schreeb, J.

Abstract:
Background

Four and a half million people die globally every year due to traumatic injuries. One major cause of preventable death is bleeding. Blood for transfusion is often unavailable in resource-limited settings, where a majority of trauma deaths occur. Intraoperative autotransfusion (IAT) has been proposed as a safe and feasible lifesaving alternative to allogeneic blood transfusion. However, there is limited knowledge regarding its use among doctors working for international non-governmental organisations (INGOs) in resource-limited settings. The aim of this study was to explore the experiences and perceptions of IAT among INGO-affiliated medical doctors with clinical experience in resource-limited settings.

Methods

We conducted semi-structured interviews via telephone or Skype with 12 purposefully sampled surgeons and anaesthesiologists. The interviews were recorded, transcribed verbatim, and analysed using content analysis.

Results

We identified three main themes relating to IAT and bottlenecks preventing the scale-up of its use: variation in techniques and systems, contextual factors, and individual medical doctor factors. The participants gave detailed reports of missed opportunities for usage of IAT in resource-limited settings. Bottlenecks included the lack of simple and cost-effective products, limited availability of protocols in the field, and insufficient knowledge and experience of IAT.

Conclusions

The participants found that simple IAT is under-utilised in resource-limited settings. Missed opportunities to use IAT were mainly associated with armed conflict settings and obstetrical emergencies. In order to meet the need for IAT in resource-limited settings, we suggest further consideration of the identified bottlenecks.

URL: https://rdcu.be/b8Tsi

 


The Efficacy of Neoadjuvant Versus Adjuvant Therapy for Resectable Esophageal Cancer Patients

 

Author list:
Xiao, X., Hong, H.G., Zeng, X. et al.

Abstract:
Objective

Inconclusive results are available as to whether chemo/radiotherapy should be administered to resectable esophageal cancer patients before surgery (neoadjuvant therapy) or after surgery (adjuvant therapy). The paper, via a meta-analysis of effects of treatment modalities when administering chemo/radiotherapy, aims to systematically evaluate the effect of timing of chemo/radiotherapy and surgery.

Methods

We performed a systematic literature search for clinical trials of neoadjuvant and adjuvant therapy for patients with esophageal cancer. Using meta-analysis, we conducted direct and adjusted indirect comparisons of overall survival, complete resection rate (R0 resection), perioperative mortality, leakage rate and local recurrence in patients with resectable esophageal cancer.

Results

A total of 32 studies involving 7985 patients with esophageal cancer were included in the meta-analysis. Twenty-five randomized controlled studies indirectly compared neoadjuvant/adjuvant therapy with surgery alone, while five non-randomized controlled studies and two randomized controlled studies directly compared neoadjuvant with adjuvant therapy. Neoadjuvant therapy followed by surgery, compared with surgery along with adjuvant therapy, showed a significant overall survival advantage in our pooled analysis (HR 0.88; 95% CI 0.79–0.98). Directly compared with adjuvant therapy, neoadjuvant therapy demonstrated a lower local recurrence rate (OR 0.56; 95% CI 0.43–0.74) with low heterogeneity (I2 = 1%). Neoadjuvant therapy, comparing to surgery with or without adjuvant therapy, showed a significantly higher R0 resection rate (OR 2.86; 95% CI 2.02–4.04) with moderate heterogeneity (I2 = 38%) and no significant differences in postoperative anastomotic leakage (P = 0.50). However, neoadjuvant therapy, compared with surgery adjuvant therapy, significantly increased perioperative mortality in both direct and indirect comparisons (P < 0.01).

Conclusions

We found that neoadjuvant therapy was associated with higher overall survival and R0 resection rate without increasing postoperative anastomotic leakage for patients with resectable esophageal cancer, whereas neoadjuvant therapy was associated with higher perioperative mortality after esophagectomy.

URL: https://rdcu.be/b8TsD

 


Complicated Diaphragmatic Hernia in Emergency Surgery

 

Author list:
Perrone, G., Giuffrida, M., Annicchiarico, A. et al.

Abstract:
Introduction

Complicated diaphragmatic hernia (DH) can be congenital or acquired. Congenital diaphragmatic hernias (CDH) are rare and often can be asymptomatic until adulthood. Traumatic diaphragmatic hernia (TDH) is a complication that occurs in about 1–5% of victims of road accidents and in 10–15% of penetrating traumas of the lower chest. CDH and TDH are potentially life-threatening conditions, and the management in emergency setting still debated. This study aims to evaluate the surgical treatment options in emergency setting.

Methods

A bibliographic research reporting the item “emergency surgery” linked with “traumatic diaphragmatic rupture” and “congenital diaphragmatic hernia” was performed. Several parameters were recorded including sex, age, etiology, diagnosis, treatment, site and herniated organs.

Results

The research included 146 articles, and 1542 patients were analyzed. Most of the complicated diaphragmatic hernias occurred for a diaphragmatic defect due to trauma, only 7.2% occurred for a congenital diaphragmatic defect. The main diagnostic method used was chest X-ray and CT scan. Laparotomic approach still remains predominant compared to the minimally invasive approach.

Conclusion

Surgery is the treatment of choice and is strongly influenced by the preoperative setting, performed mainly with X-ray and CT scan. Minimally invasive approach is safe and feasible but is highly dependent on the surgeon's expertise, especially in emergency setting.

URL: https://rdcu.be/b8TsS

 


My First Paper: The Impact of Accidental Hypothermia on Mortality in Trauma Patients Overall and Patients with Traumatic Brain Injury Specifically

 

Author list:
Rösli, D., Schnüriger, B., Candinas, D. et al.

Abstract:
Background

Accidental hypothermia is a known predictor for worse outcomes in trauma patients, but has not been comprehensively assessed in a meta-analysis so far. The aim of this systematic review and meta-analysis was to investigate the impact of accidental hypothermia on mortality in trauma patients overall and patients with traumatic brain injury (TBI) specifically.

Methods

This is a systematic review and meta-analysis using the Ovid Medline/PubMed database. Scientific articles reporting accidental hypothermia and its impact on outcomes in trauma patients were included in qualitative synthesis. Studies that compared the effect of hypothermia vs. normothermia at hospital admission on in-hospital mortality were included in two meta-analyses on (1) trauma patients overall and (2) patients with TBI specifically. Meta-analysis was performed using a Mantel–Haenszel random-effects model.

Results

Literature search revealed 264 articles. Of these, 14 studies published 1987–2018 were included in the qualitative synthesis. Seven studies qualified for meta-analysis on trauma patients overall and three studies for meta-analysis on patients with TBI specifically. Accidental hypothermia at admission was associated with significantly higher mortality both in trauma patients overall (OR 5.18 [95% CI 2.61–10.28]) and patients with TBI specifically (OR 2.38 [95% CI 1.53–3.69]).

Conclusions

In the current meta-analysis, accidental hypothermia was strongly associated with higher in-hospital mortality both in trauma patients overall and patients with TBI specifically. These findings underscore the importance of measures to avoid accidental hypothermia in the prehospital care of trauma patients.

URL: https://rdcu.be/b8Tta

 


 

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