Featured Articles in Dec 2022

Inspirational Women in Surgery: Inspirational Women in Surgery: Professor Kokila Lakhoo, South Africa

 

Author list: Ruth Laverde & Doruk Ozgediz

 

No Abstract

 

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ERAS: Analysis of Compliance with Enhanced Recovery After Surgery (ERAS) Protocol for Esophagectomy

 

Author list: 

Francesco Puccetti, Fredrik Klevebro, MadhanKumar Kuppusamy, Shiwei Han, Richard E. Fagley, Donald E. Low & Michal Hubka

 

 

 

Abstract

Background

ERAS guidelines have provided an effective recovery approach for esophagectomy. This study aimed to identify the relationship between the length of hospital stay (LOS) and compliance with clinical benchmarks of an established institutional ERAS program.

 

Methods

A single-center prospective database of esophageal cancer patients was retrospectively analyzed between January 2016 and January 2020. All patients underwent surgery within a standardized ERAS pathway for esophagectomy. Compliance with individual ERAS benchmarks and postoperative outcomes were evaluated according to patient’s LOS; accelerated (≤ 6 days, AR), targeted (7–8 days, TR), and delayed recovery (≥ 9 days, DR).

 

Results

The study included 100 consecutive patients undergoing esophagectomy with a median LOS of 7 (3.8–40.8) days, and a 30-day readmission rate of 12.6%. LOS was not affected by comorbidities, tumor type or stage, neoadjuvant therapy, operative approach or anastomotic leak. Postoperative complications were 49.5%, and 90-day mortality was 3.8%. AR, TR, and DL were achieved by 45%, 31%, and 24% of patients, respectively. Postoperative morbidity differed significantly among groups, impacting LOS (p < 0.001). Overall compliance with ERAS protocol was 82.7% and adherence to specific benchmarks was initially (< 48 h) high, but significantly affected by postoperative complications afterwards.

 

Conclusions

Adherence to recovery benchmarks in patients undergoing esophagectomy is most commonly impacted by postoperative complications. In esophageal cancer surgery, the adherence to ERAS benchmarks after esophagectomy should be regularly audited. Modification to ERAS protocols to increase application in patients with complications should be considered.

 

 

 

 

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Ukraine War: Ukraine's Experience with Management of Combat Casualties Using NATO's Four-Tier "Changing as Needed" Healthcare System

 

 

Author list:

Anatoliy Kazmirchuk, Yurii Yarmoliuk, Igor Lurin, Rostislav Gybalo, Olexandr Burianov, Serhii Derkach & Kostiantyn Karpenko

 

*VISUAL ABSTRACT* coming soon

 

Abstract

Introduction

The full-scale war with Russia on the territory of Ukraine has revealed several problems related to care of the wounded. In this article, we summarize the mechanisms of injury and injuries sustained for the period February to April 2022, focusing on extremity injuries.

 

Materials and methods

We compared these to a period of lower-intensity warfare in 2014–2021. In both cases, we report patients treated by the National Military Medical Clinical Center (NMMCC) in Kyiv. We also sought to evaluate the care of the wounded from an organizational viewpoint, taking into account the four-level system of care also used by the North Atlantic Treaty Organization (NATO). Third, we sought to understand lessons learned that could improve the care of the wounded.

 

Conclusion

During the 2022 conflict, the percentage of patients with extremity wounds who had long bone fractures increased and the percentage of people with long bone fractures who had bone defects increased, compared with 2014–2021. This may be due to the higher blast energy from the weapons used in the current conflict. Second, we adapted the four-level NATO system of care. Level 2 (first level hospital) care was provided by civilian hospitals close to the fighting, rather than mobile military hospitals. Level 3 (specialized) and 4 (highly specialized) care were combined into one hospital (NMMCC). This is the first description of flexible use of NATO's four levels. Finally, a major lesson learned was the need to improve use of damage control surgery.

 

 

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Turnover Time Between Elective Operative Cases: Does the Witching Hour Exist for the Operating Room?

 

Author list:

Stanley Kamande, Kwadwo Sarpong, Jerome Murray, Ayodeji Ajayi, Ehsan Dowlati & M. Nathan Nair  

*VISUAL ABSTRACT* coming soon

 

Abstract

Background

Efficient resource management in the operating room (OR) contributes significantly to healthcare expenditure and revenue generation for health systems. We aim to assess the influence that surgeon, anesthesiology, and nursing team assignments and time of day have on turnover time (TOT) in the OR.

 

Methods

We performed a retrospective review of elective cases at a single academic hospital that were completed between Monday and Friday between the hours of 0700 and 2359 from July 1, 2017, through March 31, 2018. Emergent cases and unplanned, add-on cases were excluded. Data regarding patient characteristics, OR teams, TOT, and procedure start and end times were collected and analyzed.

 

Results

A total of 2174 total cases across 13 different specialties were included in our study. A multivariate regression of relevant variables affecting TOT was performed. Consecutive specialty (p < 0.0001), consecutive surgeon (p < 0.0001), anesthesiologist (p < 0.0001), and prior case ending before 1400 (p < 0.0001) were independent predictors of lower TOT. A receiver operating characteristic analysis demonstrated an area under the curve of 0.848 and a cutoff of 1400 having the highest sensitivity and specificity for TOT difference.

 

Conclusions

TOT can be significantly affected by the time of the day the procedure is performed. Staffing availability during late procedures and the differences in how OR team staff are scheduled may affect OR efficiency. Additional studies may be needed to determine the long-term implications of changes implemented to decrease organizational operational costs related to the OR.

 

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Care Fragmentation in Patients with Differentiated Thyroid Cancer

Author list: 

Jacques A. Greenberg, Jessica W. Thiesmeyer, Caitlin E. Egan, Yeon Joo Lee, Maheshwaran Sivarajah, Rasa Zarnegar, Thomas J. Fahey III, Toni Beninato & Brendan M. Finnerty

 

Abstract

Background

Among surgical patients, care fragmentation (CF) is associated with worse outcomes. However, oncologic literature documents an association between high surgical volume and improved outcomes, favoring centralized cancer-surgery centers and thus predisposing to CF in patients with surgically treated tumors. We aimed to identify features associated with CF and ascertain differences in overall survival (OS) among patients with differentiated thyroid cancer (DTC).

 

Methods

The National Cancer Database was queried for DTC patients diagnosed from 2009 to 2017. Patients experienced CF if part of their treatment was performed outside of the reporting facility or an associated office. A multivariable logistic regression analysis identified independent features associated with CF. A Cox multivariable regression analysis assessed the impact of CF on OS. A Kaplan–Meier analysis compared survival differences between patients experiencing CF or unified care (UC).

 

Results

A total of 131,620 patients were included. Among them, 70,204 (53.3%) experienced CF and 61,416 (46.7%) experienced UC. Age < 55, residing in high-income areas, and stage 3 and 4 tumors were features independently associated with CF, whereas uninsured patients were less likely to experience CF than the privately insured. The features most strongly associated with CF were treatment at highest thyroid cancer-surgery volume institutions and traveling in the top distance quartile. While patients with CF experienced minor delays in time from diagnosis to surgery, 5-year OS was improved among patients with CF compared to UC for those with Stage 1–3 disease.

 

Conclusions

Among patients with DTC, CF is associated with treatment at a highest thyroid cancer surgery volume facility and improved OS in a setting of minor treatment delays.

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‘Breast Cosmesis After Breast-Conserving Therapy’ Who is the Judge, Patient or Surgeon?

 

Author list: 

Alton Wern Jie Hong, J. James, D. Stoney & M. Law

 

Abstract

Introduction

More than 80% of newly diagnosed breast cancers are managed with breast-conserving therapy (BCT). Preservation of cosmetically acceptable breasts is an inherent aim of all breast-conserving efforts—this can, however, be difficult to assess objectively. Compounding this is the difference in perception of breast cosmesis between patients and surgeons. This study compares the concordance of a new subscale-based cosmetic score (TCS) with the patient’s perception.

 

Method

Eastern Health Breast and Cancer Centre conducted this study on patients who had completed their BCT and radiotherapy. Participation was voluntary and involved permitting an assessor (breast surgery fellow or consultant) to grade cosmetic outcomes to generate a Total Cosmesis Score (TCS). The patients blinded to this assessment were then asked to complete the postoperative segment of the BCT module of the Breast-Q questionnaire. TCS from surgeon assessment was compared against patient assessment (questions BQ1i and BQ1k specifically). Cohen’s kappa was calculated to define the strength of the inter-rater agreement.

 

Results

One hundred twelve patients with a mean age of 59 (range 27–89) participated in the study. TCS was low in 26% and high in 74% of participants. 76% and 69% of participants were satisfied when answering Breast-Q questions ‘How your lumpectomy breast looks?’ and ‘How you look in the mirror unclothed?’ respectively (Cohen's k = 0.464, 95% CI 0.337–0.591, p < 0.01). The agreement between the TCS and the patient assessment was poor (Cohen’s k = 0.172, 95% CI − 0.020–2.093, p = 0.067).

 

Conclusion

Cosmetic outcomes scored using TCS by surgeons do not match patient's own assessment of the cosmetic result.

 

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My First Paper: Hispanic Farmers Experience Shorter EMS Response Times but Longer Emergency Department Length of Stay Following Occupational Injuries

 

Author list: 

Chloe M. Young, Suraj Panjwani, Nicholas Druar & Mitchell A. Cahan

 

*** - Chloe Young is a fourth-year student at UMass Chan T.H. Chan School of Medicine. Originally from Colorado, she is passionate for understanding the healthcare needs of individuals who make up the beloved rural communities in Colorado and throughout the United States. This passion has fueled a desire to join the Population-Based Urban and Rural Community Health (PURCH) Track offered by UMass Chan, which provides opportunities to incorporate social determinants of health into clinical practice and develop advocacy skills for underserved populations. She looks forward to leveraging her career as a physician-scientist to promote research and innovative advancements in healthcare delivery.

 

Abstract

Background

Agriculture has the highest rate of fatal injuries by sector. Hispanic workers also experience more fatal work injuries than every other minority group combined. Pre-hospital and initial trauma evaluation represent an important marker to understand the impact of a trauma system. We sought to investigate whether Hispanic agricultural workers in the United States (US) experience disparities following traumatic occupational injuries in terms of pre-hospital and emergency department care.

 

Methods

We retrospectively analyzed the National Trauma Data Bank from 2012–2016 to understand differences between Hispanic and non-Hispanic farmers in Emergency Medical Services (EMS) response and transport times (minutes), transport mode, transfer rates, presentation to University or Level I trauma hospitals, Injury Severity Scores (ISS), length of stay (LOS) in the emergency department (ED, minutes) or hospital (days), need for the operating room (OR), admittance to the Intensive Care Unit (ICU), and mortality.

 

Results

A total of 6,161 farmers were included in our analyses (median age 47 years, females 7.0%). Multivariable analyses indicate differences regarding EMS response, EMS transport, and LOS in the ED. Rates of admission to the ICU, surgical operations, days on a ventilator, discharge from the hospital with supportive care, and mortality did not differ between groups.

 

Conclusions

Non-Hispanic patients have longer median EMS response and total transport times. Hispanic patients have longer median LOS in the ED. However, the lack of significant differences in management variables other than EMS times and ED LOS indicate an equitable delivery of trauma care once patients were transferred from the ED.

 

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Systematic Review of the Association Between Trauma Severity and Postinjury Symptoms of Depression

 

Author list:

Yvonne Versluijs, Thomas W. van Ravens, Pieta Krijnen, David Ring & Inger B. Schipper

Abstract

Background

Greater symptoms of depression are associated with greater symptom intensity during recovery from musculoskeletal injury. It is not clear that more severe trauma is associated with greater symptoms of depression as one might expect. The goal of this study was to systematically review the existing evidence regarding the association of Injury Severity Score (ISS) with symptoms of depression during recovery from musculoskeletal injury.

 

Methods

Two independent reviewers used PubMed and Embase to identify studies that measured both ISS and symptoms of depression. Among the 17 studies satisfying inclusion criteria, 5 studies assessed the correlation of symptoms of depression and ISS on their continuum; 3 studies compared the mean of symptoms of depression for people above and below a specific ISS level; five compared mean ISS above and below a threshold level of symptoms of depression; and four compared dichotomized ISS and dichotomized depression. Four of the 17 evaluated factors associated with symptoms of depression in multivariable analysis.

 

Results

In bivariate analysis, 12 of 17 studies (71%) found no association between ISS level and symptoms of depression. Three studies found a bivariate association that did not persist in multivariable analysis. Two studies reported slight associations in bivariate analysis, but did not perform multivariable analysis.

 

Conclusions

The knowledge that symptoms of depression are common during recovery, in combination with the finding of this review that they have little or no relationship with injury severity, directs clinicians to anticipate and address mental health during recovery from physical trauma of any severity.

 

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Platelet-Rich Plasma (PRP) for Sacrococcygeal Pilonidal Disease: An Updated Systematic Review and Meta-Analysis

 

 

Author list:

C. F. Brewer, I. F. S. Correia & B. H. Miranda

 

Abstract

Background

Pilonidal disease can be a debilitating condition which carries a significant physical and economic burden. This systematic review and updated meta-analysis presents the evidence for the use of platelet-rich plasma (PRP) for wound healing following open and minimally-invasive sacrococcygeal pilonidal surgery.

 

Methods

A literature search was performed during December 2021 for studies relating to platelet-rich plasma and pilonidal wound healing following surgery.

 

Results

Nine studies remained after applying the exclusion criteria, incorporating a total of 621 (open surgery group) and 309 (minimally-invasive group) patients, respectively. Pooled analysis of the six open surgery group studies demonstrated a significant reduction in wound healing time (mean difference [MD] = − 13.98 days, 95% CI − 18.41 to − 9.55, p < 0.001, I2 = 98%). Three open surgery group studies compared post-operative time off work, while three recorded mean pain duration; pooled analysis also revealed a significant reduction in both outcomes, respectively (MD = − 8.7 days, 95% CI − 9.4 to − 8.0, p < 0.001, I2 = 57%; MD = − 9.5 days, 95% CI − 15.6 to − 3.3, p = 0.002, I2 = 98%). Methodological heterogeneity among the minimally-invasive studies precluded formal meta-analysis; however, two studies demonstrated a modest improvement in wound healing when treated with PRP.

 

Conclusions

This systematic review and updated meta-analysis provide further evidence supporting the use of PRP for wound healing in sacrococcygeal pilonidal disease. PRP application was demonstrated to significantly reduce healing time, postoperative pain and time off work in the open surgery group. Nevertheless, there is still considerable heterogeneity among PRP manufacture and administration techniques, and further high-powered RCTs with consistent methodology are required to substantiate these findings.

 

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Fascial Dehiscence and Incisional Hernia Prediction Models: A Systematic Review and Meta-analysis

 

 

Author list:

Amarit Tansawet, Pawin Numthavaj, Thawin Techapongsatorn, Suphakarn Techapongsatorn, John Attia, Gareth McKay & Ammarin Thakkinstian

 

Abstract

Background

Fascial dehiscence (FD) and incisional hernia (IH) pose considerable risks to patients who undergo abdominal surgery, and many preventive strategies have been applied to reduce this risk. An accurate predictive model could aid identification of high-risk patients, who could be targeted for particular care. This study aims to systematically review existing FD and IH prediction models.

 

Methods

Prediction models were identified using pre-specified search terms on SCOPUS, PubMed, and Web of Science. Eligible studies included those conducted in adult patients who underwent any kind of abdominal surgery, and reported model performance. Data from the eligible studies were extracted, and the risk of bias (RoB) was assessed using the PROBAST tool. Pooling of C-statistics was performed using a random-effect meta-analysis. [Registration: PROSPERO (CRD42021282463)].

 

Results

Twelve studies were eligible for review; five were FD prediction model studies. Most included studies had high RoB, especially in the analysis domain. The C-statistics of the FD and IH prediction models ranged from 0.69 to 0.92, but most have yet to be externally validated. Pooled C-statistics (95% CI) were 0.80 (0.74, 0.86) and 0.81 (0.75, 0.86) for the FD (external-validation) and IH prediction model, respectively. Some predictive factors such as body mass index, smoking, emergency operation, and surgical site infection were associated with FD or IH occurrence and were included in multiple models.

 

Conclusions

Several models have been developed as an aid for FD and IH prediction, mostly with modest performance and lacking independent validation. New models for specific patient groups may offer clinical utility.

 

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Machine Learning Algorithms for Predicting Surgical Outcomes after Colorectal Surgery: A Systematic Review

 

Author list:

Mustafa Bektaş, Jurriaan B. Tuynman, Jaime Costa Pereira, George L. Burchell & Donald L. van der Peet

 

Abstract

Background

Machine learning (ML) has been introduced in various fields of healthcare. In colorectal surgery, the role of ML has yet to be reported. In this systematic review, an overview of machine learning models predicting surgical outcomes after colorectal surgery is provided.

 

Methods

Databases PubMed, EMBASE, Cochrane, and Web of Science were searched for studies using machine learning models for patients undergoing colorectal surgery. To be eligible for inclusion, studies needed to apply machine learning models for patients undergoing colorectal surgery. Absence of machine learning or colorectal surgery or studies reporting on reviews, children, study abstracts were excluded. The Probast risk of bias tool was used to evaluate the methodological quality of machine learning models.

 

Results

A total of 1821 studies were analysed, resulting in the inclusion of 31 articles. A vast proportion of ML algorithms have been used to predict the course of disease and response to neoadjuvant chemoradiotherapy. Radiomics have been applied most frequently, along with predictive accuracies up to 91%. However, most studies included a retrospective study design without external validation or calibration.

 

Conclusions

Machine learning models have shown promising potential in predicting surgical outcomes after colorectal surgery. However, large-scale data is warranted to bridge the gap between calibration and external validation. Clinical implementation is needed to demonstrate the contribution of ML within daily practice.

 

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