Featured Articles in Dez 2019

Factors Influencing a Medical Student’s Decision to Pursue Surgery as a Career

 

Author list 

Jarod Shelton, Michael Obregon, Jessica Luo, Oren Feldman-Schultz, Martin MacDowell

 

 

Abstract

Background

Recent match trends from the National Resident Matching Program suggest that the number of allopathic medical students (MD) pursuing general surgery is declining. This decline may have profound consequences given the surgeon shortage predicted by the Association of American Medical Colleges. Early exposure to surgery opportunities may increase a student’s desire to pursue the specialty as a career. The aim of this study was to evaluate the effect surgical activities have on promoting student interest in surgery.

 

Methods

Medical students (years 1–3) at the University of Illinois at Rockford completed a two-component activity: a questionnaire and laparoscopic box activity. Differences in lifestyle factors, psychomotor aptitude, and future career interests were compared.

 

Results

A total of 64 medical students completed the activity. 45.3% of students reported that the activity positively influenced their decision to pursue a career in surgery. Rating of the importance of living in a rural versus urban community was an important lifestyle factor (p = 0.01) for students without rather than with an interest in surgery, 3.95 and 3.19, respectively. No differences were observed in other lifestyle factors.

 

Conclusion

Early exposure to surgical activities may foster interest in students who lacked previous intention to pursue the specialty.

 

URL- https://rdcu.be/bXjSE

 


Outcomes Following Major Oncologic Operations for Non-AIDS-Defining Cancers in the HIV Population

 

Author list 

Amber Chi, Bryan E. Adams, Joanna Sesti, Subroto Paul, Amber L. Turner, David August, Darren Carpizo, Timothy Kennedy, Miral Grandhi, H. Richard Alexander, Steven K. Libutti, Stuart Geffner, Russell C. Langan

 

Abstract

Introduction

Human immunodeficiency virus (HIV) patients are living longer due to the availability of antiretroviral therapies, and non-AIDS-defining cancers are becoming more prevalent in this patient population. A paucity of data remains on post-operative outcomes following resection of non-AIDS-defining cancers in the HIV population.

 

Methods

The National Inpatient Sample was utilized to identify patients who underwent surgical resection for malignancy from 2005 to 2015 (HIV, N = 52,742; non-HIV, N = 11,885,184). Complications were categorized by international classification of disease (ICD)-9 diagnosis codes. Cohorts were matched on insurance, household income, zip code and urban/rural setting. Logistic regression assessed whether HIV was an independent predictor of post-operative complications.

 

Results

Descriptive statistics found HIV patients to have an increased rate of complications following select oncologic surgical resections. Univariate and multivariate logistic regression found HIV to only be an independent predictor of complications following pulmonary lobectomy (p = 0.011; OR 2.93, 95% CI 1.29–6.73). Length of stay was statistically longer following colectomy (2.61 days, 95% CI 1.98–3.44) in those with HIV.

 

Conclusions

Our findings are hypothesis generating and highlight the potential safety of major cancer surgery in the HIV population. However, care providers need be cognizant of the potential increased risk of post-operative complications following pulmonary lobectomy and the potential for increased length of stay. These findings are an initial insight into quality of care and outcomes metrics on HIV patients undergoing major cancer operations.

 

 

URL https://rdcu.be/bXjTj

 


Sex-Based Differences in Inpatient Burn Mortality

 

 

Author list 

Felicia N. Williams, Paula D. Strassle, Laquanda Knowlin, Sonia Napravnik, David van Duin, Anthony Charles, Rabia Nizamani, Samuel W. Jones, Bruce A. Cairns

 

Abstract

Background

Among burn patients, research is conflicted, but may suggest that females are at increased risk of mortality, despite the opposite being true in non-burn trauma. Our objective was to determine whether sex-based differences in burn mortality exist, and assess whether patient demographics, comorbid conditions, and injury characteristics explain said differences.

 

Methods

Adult patients admitted with burn injury—including inhalation injury only—between 2004 and 2013 were included. Inverse probability of treatment weights (IPTW) and inverse probability of censor weights (IPCW) were calculated using admit year, patient demographics, comorbid conditions, and injury characteristics to adjust for potential confounding and informative censoring. Standardized Kaplan–Meier survival curves, weighted by both IPTW and IPCW, were used to estimate the 30-day and 60-day risk of inpatient mortality across sex.

 

Results

Females were older (median age 44 vs. 41 years old, p < 0.0001) and more likely to be Black (32% vs. 25%, p < 0.0001), have diabetes (14% vs. 10%, p < 0.0001), pulmonary disease (14% vs. 7%, p < 0.0001), heart failure (4% vs. 2%, p = 0.001), scald burns (45% vs. 26%, p < 0.0001), and inhalational injuries (10% vs. 8%, p = 0.04). Even after weighting, females were still over twice as likely to die after 60 days (RR 2.87, 95% CI 1.09, 7.51).

 

Conclusion

Female burn patients have a significantly higher risk of 60-day mortality, even after accounting for demographics, comorbid conditions, burn size, and inhalational injury. Future research efforts and treatments to attenuate mortality should account for these sex-based differences. The project was supported by the National Institutes of Health, Grant Number UL1TR001111.

 

URL https://rdcu.be/bXjUD

 


Impact of Intermittent Pringle Maneuver on Long-Term Survival After Hepatectomy for Hepatocellular Carcinoma

 

Author list 

Kit Fai Lee, Charing C. N. Chong, Sunny Y. S. Cheung, John Wong, Andrew K. Y. Fung, Hon Ting Lok, Paul B. S. Lai

 

Abstract

Background

Hepatectomy remains an important curative treatment for hepatocellular carcinoma (HCC). Intermittent Pringle maneuver (IPM) is commonly applied during hepatectomy for control of bleeding. Whether the ischemia/reperfusion injury brought by IPM adversely affects the operative outcomes is controversial. This study aims to examine whether the application of IPM during hepatectomy affects the long-term outcomes.

 

Methods

Two randomized controlled trials (RCT) have been carried out previously to evaluate the short-term outcomes of IPM. The present study represented a post hoc analysis on the HCC patients from the first RCT and all patients from the second RCT, and the long-term outcomes were evaluated.

 

Results

There were 88 patients each in the IPM group and the no-Pringle-maneuver (NPM) group. The patient demographics, type and extent of liver resection and histopathological findings were comparable between the two groups. The 1-, 3-, 5-year overall survival in the IPM and NPM groups was 92.0%, 82.0%, 72.1% and 93.2%, 68.8%, 58.1%, respectively (P = 0.030). The 1-, 3-, 5-year disease-free survival in the IPM and NPM groups was 73.6%, 56.2%, 49.7% and 71.6%, 49.4%, 40.3%, respectively (P = 0.366). On multivariable analysis, IPM was a favorable factor for overall survival (P = 0.035). Subgroup analysis showed that a clamp time of 16–30 min (P = 0.024) and cirrhotic patients with IPM (P = 0.009) had better overall survival.

 

Conclusion

IPM provided a better overall survival after hepatectomy for patients with HCC. Such survival benefit was noted in cirrhotic patients, and the beneficial duration of clamp was 16–30 min.

 

URL https://rdcu.be/bXkuV

 


Long-Term Outcomes of Pulmonary Resection for Lung Cancer Patients with Chronic Kidney Disease

Author list 

Yoko Yamamoto, Ryu Kanzaki, Takashi Kanou, Naoko Ose, Soichiro Funaki, Masato Minami, Yasushi Shintani

 

Abstract

Background

The survival outcome in lung cancer patients with chronic kidney disease (CKD) has not been well evaluated. The aim of this study was to evaluate the survival outcomes following non-small cell lung cancer (NSCLC) surgery in patients with CKD as a preoperative comorbidity.

 

Methods

Among 671 patients who underwent surgery for NSCLC between 2007 and 2014 at our hospital, 55 (8%) had CKD and we retrospectively analyzed the survival outcomes of these patients.

 

Results

Most patients with CKD were elderly and male. Patients with CKD had a higher frequency of smoking habit, cardiovascular disease, and pulmonary diseases, and a notably lower pulmonary function, resulting in receiving limited pulmonary resection. There were no marked differences in the frequency of surgical complications between patients with and without CKD (p = 0.16). Squamous cell carcinoma was more frequently diagnosed in patients with CKD than in those without it. The 5-year disease-free survival rates in patients with and without CKD were 60.0% and 69.7% (p = 0.06), respectively, and the 5-year overall survival rates were 68.9% and 80.0%, respectively, showing significant differences (p = 0.01). The rate of receiving supportive care was higher in patients with CKD when recurrence observed.

 

Conclusion

CKD is associated with a poorer overall survival in patients who undergo lung cancer resection for recurrent disease. As patients with CKD tend to have a poor respiratory function, thoracic surgeons should carefully select the resection type to balance the therapeutic benefit and invasiveness.

 

URL https://rdcu.be/bXkt1

 


A Systematic Review of Opt-out Versus Opt-in Consent on Deceased Organ Donation and Transplantation

 

Author list 

M. Usman Ahmad, Afif Hanna, Ahmed-Zayn Mohamed, Alex Schlindwein, Caitlin Pley, Ingrid Bahner, Rahul Mhaskar, Gavin J. Pettigrew, Tambi Jarmi

 

Abstract

Background

Significant numbers of patients in the USA and UK die while waiting for solid organ transplant. Only 1–2% of deaths are eligible as donors with a fraction of the deceased donating organs. The form of consent to donation may affect the organs available. Forms of consent include: opt-in, mandated choice, opt-out, and organ conscription. Opt-in and opt-out are commonly practiced. A systematic review was conducted to determine the effect of opt-in versus opt-out consent on the deceased donation rate (DDR) and deceased transplantation rate (DTR).

 

Methods

Literature searches of PubMed and EMBASE between 2006 and 2016 were performed. Research studies were selected based on certain inclusion criteria which include USA, UK, and Spain; compare opt-in versus opt-out; primary data analysis; and reported DDR or DTR. Modeled effect on US transplant activity was conducted using public data from Organ Procurement and Transplantation Network and Centers for Disease Control WONDER from 2006 to 2015.

 

Results

A total of 2400 studies were screened and six studies were included. Four studies reported opt-out consent increases DDR by 21–76% over 5–14 years. These studies compared 13–25 opt-out countries versus 9–23 opt-in countries. Three studies reported opt-out consent increases DTR by 38–83% over 11–13 years. These studies compared 22–25 opt-out versus 22–28 opt-in countries. Modeled opt-out activity on the USA resulted in 4753–17,201 additional transplants annually.

 

Conclusion

Opt-out consent increases DDR and DTR and may be useful in decreasing deaths on the waiting list in the USA and other countries.

 

 

URL https://rdcu.be/bXktg

 


Lateral Pelvic Lymph Node Metastases in Rectal Cancer: A Systematic Review

Author list 

Y. Atef, T. W. Koedam, S. E. van Oostendorp, H. J. Bonjer, A. R. Wijsmuller, J. B. Tuynman

 

Abstract

Background

Synchronous lateral pelvic lymph node (LPLN) involvement occurs in a significant number of patients with rectal cancer. The aim of this study is to determine the rate of LPLN metastases in rectal cancer patients with LPLN suspicious for metastases (LPLNSM) on pretreatment imaging, treated with neoadjuvant chemoradiotherapy (nCRT). Additionally, the influence of LPLN responsiveness to nCRT as determined by post-nCRT restaging scan was investigated.

 

Methods

A systematic review was conducted to identify studies on patients with author-defined LPLNSM that reported the pathological outcomes after total mesorectal excision (TME) with lateral pelvic lymph node dissection (LPLD). MEDLINE, EMBASE, Web of Science and the Cochrane Library were searched. The primary outcome was the percentage of pathologically confirmed LPLN metastases.

 

Results

A total of 462 patients from eleven studies were identified. The number of pathologically confirmed LPLN metastases in 361 patients that underwent uni- or bilateral LPLD ranged from 21.9 to 61.1%. The LPLD resulted in pathologically confirmed metastases in a range from 0 to 20.4% of patients with responsive LPLNSM and in a range from 25.0 to 83.3% of patients with persistent nodes. However, radiologic cutoff criteria for the evaluation of LPLN differed between studies.

 

Conclusions

In a large number of patients with LPLNSM on initial imaging, metastatic LPLN are present after nCRT and surgical treatment. Even in LPLN that are considered responsive on restaging, significant rates of pathologically confirmed metastases are reported.

 

URL https://rdcu.be/bXksk

Open and Endovascular Management of Acute Mesenteric Ischaemia: A Systematic Review

Author list 

B Murphy, C. H. C. Dejong, D. C. Winter

 

Abstract

Background

Acute mesenteric ischaemia (AMI) is a life-threatening surgical emergency resulting from thromboembolic occlusion of the mesenteric vasculature. Traditional management of AMI has been open revascularisation with or without bowel resection—a procedure which carries considerable morbidity and mortality in an already unwell, compromised patient. Endovascular and more minimally invasive management approaches to AMI have been reported. Proponents of endovascular management suggest this approach may be associated with reduced morbidity and mortality compared with open surgery.

 

Objectives

To assess the impact of endovascular approach for AMI on mortality and need for subsequent laparotomy and/or bowel resection.

 

Data Sources

The search bodies PubMed and Medline were interrogated.

 

Eligibility Criteria, Participants and Interventions

All studies in English with greater than 10 patients examining outcomes for patients undergoing endovascular intervention for acute mesenteric ischaemia were included. All patients over 18 years presenting with a diagnosis of acute mesenteric ischaemia secondary to an arterial thromboembolic source were included. Studies examining endovascular intervention alone or endovascular and open intervention were selected.

 

Results

The 30-day mortality for endovascular approach from all 13 studies was 16–42%. Of the 7 comparative studies including results of open revascularisation, the 30-day mortality for patient treated with an endovascular approach was 15–39% versus 33–50% for open revascularisation. Laparotomy rates post-initial endovascular intervention ranged from 13 to 73%. Bowel resection post-endovascular therapy ranged from 14 to 40% among studies. Concerning 7 comparative studies for open versus endovascular revascularisation, the rate of bowel resection in the endovascular group ranged 14–28% and 33–63% in the open cohort. Endovascular intervention also demonstrated lower median length (s) of bowel resected.

 

Limitations

Heterogeneity of studies and patient populations studied including selection bias.

 

Conclusions and implications of findings

Endovascular management may be associated with reduced mortality and need for/length of bowel resection compared with the traditional open approach, but there remains a paucity of robust data to support this. The available literature illustrates that a subgroup of patients without haemodynamic compromise and more insidious onset may garner benefit from endovascular intervention.

 

URL https://rdcu.be/bXkix

 

BACK