Featured Articles in Feb 2021

Risk Score of Neck Hematoma: How to Select Patients for Ambulatory Thyroid Surgery?

Author list:

Nathalie Chereau, Gaelle Godiris-Petit, Severine Noullet, Sophie Di Maria, Sophie Tezenas du Montcel & Fabrice Menegaux

 

Abstract:

Background

The risk of postoperative compressive hematoma is the major limitation for a wide development of ambulatory thyroidectomy (AT). The aim of this study was to establish a risk score of hematoma on the basis of preoperative criteria.

Methods

All patients who underwent thyroidectomy between 2002 and 2017 were reviewed in a high-volume endocrine surgery center. Multivariate analysis of risk factors associated with hematoma was performed in lobectomy and total thyroidectomy (TT). We assigned the risk factors identified by multivariate analysis weighted points proportional to the regression coefficient values. A simple sum of all accumulated points for each patient calculated the total score.

Results

For lobectomy [31 hematoma among 3912 patients (0.8%)], the weighted points of Vit K antagonist (VKA) were 3 (OR 9.86), and 1 in male gender (OR 2.4). For TT [162 hematoma among 13,903 patients (1.2%)], the weighted points of VKA were 4 (OR 12.18), 1 in male gender (OR 1.89), and 1 for diabetes (OR 1.86). Other factors weighted 0 in both groups. A total score >1 was linked to a risk of hematoma > 1.3% for lobectomy or TT. AT should not be proposed to any patient under VKA, and in case of TT, to male patients with diabetes. Prospectively, patients had AT from May 2018 to February 2020, 529 patients underwent ambulatory TL (483) or TT (46) and only one patient experienced neck hematoma.

 

Conclusion

We established a simple and reproducible predictive score of early discharge for lobectomy and TT that could be useful for patients’ management.

 

URL: https://rdcu.be/cd3nk

 


Biosynthetic Resorbable Prosthesis is Useful in Single-Stage Management of Chronic Mesh Infection

Author list:

José Bueno-Lledó, Marsela Ceno, Carla Perez-Alonso, Jesús Martinez-Hoed, Antonio Torregrosa-Gallud & Salvador Pous-Serrano

 

Abstract:

Background

The goal of this article was to report the results about the efficacy of treatment of chronic mesh infection (CMI) after abdominal wall hernia repair (AWHR) in one-stage management, with complete mesh explantation of infected prosthesis and simultaneous reinforcement with a biosynthetic poly-4-hydroxybutyrate absorbable (P4HB) mesh.

 

Methods

This is a retrospective analysis of all patients that needed mesh removal for CMI between September 2016 and January 2019 at a tertiary center. Epidemiological data, hernia characteristics, surgical, and postoperative variables (Clavien–Dindo classification) of these patients were analyzed.

 

Results

Of the 32 patients who required mesh explantation, 30 received one-stage management of CMI. In 60% of the patients, abdominal wall reconstruction was necessary after the infected mesh removal: 8 cases (26.6%) were treated with Rives–Stoppa repair, 4 (13.3%) with a fascial plication, 1 (3.3%) with anterior component separation, and 1 (3.3%) with transversus abdominis release to repair hernia defects. Three Lichtenstein (10%) and 1 Nyhus repairs (3.3%) were performed in patients with groin hernias. The most frequent postoperative complications were surgical site occurrences: seroma in 5 (20%) patients, hematoma in 2 (6.6%) patients, and wound infection in 1 (3.3%) patient. During the mean follow-up of 34.5 months (range 23–46 months), the overall recurrence rate was 3.3%. Persistent, recurrent, or new CMIs were not observed.

 

Conclusions

In our experience, single-stage management of CMI with complete removal of infected prosthesis and replacement with a P4HB mesh is feasible with acceptable results in terms of mesh reinfection and hernia recurrence.

 

URL: https://rdcu.be/cd3nI


ERAS: A Protocol is not Enough: Enhanced Recovery Program-Based Care and Clinician Adherence Associated with Shorter Stay After Colorectal Surgery

Author list:

Ben E. Byrne, Omar D. Faiz, Alex Bottle, Paul Aylin & Charles A. Vincent

 

Abstract:

Background

Randomised trials have shown an Enhanced Recovery Program (ERP) can shorten stay after colorectal surgery. Previous research has focused on patient compliance neglecting the role of care providers. National data on implementation and adherence to standardised care are lacking. We examined care organisation and delivery including the ERP, and correlated this with clinical outcomes.

 

Methods

A cross-sectional questionnaire was administered to surgeons and nurses in August–October 2015. All English National Health Service Trusts providing elective colorectal surgery were invited. Responses frequencies and variation were examined. Exploratory factor analysis was performed to identify underlying features of care. Standardised factor scores were correlated with elective clinical outcomes of length of stay, mortality and readmission rates from 2013–15.

 

Results

218/600 (36.3%) postal responses were received from 84/90 (93.3%) Trusts that agreed to participate. Combined with email responses, 301 surveys were analysed. 281/301 (93.4%) agreed or strongly agreed that they had a standardised, ERP-based care protocol. However, 182/301 (60.5%) indicated all consultants managed post-operative oral intake similarly. After factor analysis, higher hospital average ERP-based care standardisation and clinician adherence score were significantly correlated with reduced length of stay, as well as higher ratings of teamwork and support for complication management.

 

Conclusions

Standardised, ERP-based care was near universal, but clinician adherence varied markedly. Units reporting higher levels of clinician adherence achieved the lowest length of stay. Having a protocol is not enough. Careful implementation and adherence by all of the team is vital to achieve the best results.

 

URL: https://rdcu.be/cd3nN


We Asked The Experts: Emerging Role of YouTube Surgical Videos in Education and Training

 

Author list:

Kai Siang Chan & Vishal G. Shelat

 

Abstract: N/A

URL:  https://rdcu.be/cd3o3

 


My First Paper: Pediatric Primary Hyperparathyroidism: Experience in a Tertiary Care Referral Center in a Developing Country Over Three Decades

 

Author list:

Vikram Sharanappa, Anjali Mishra, Vijayalakshmi Bhatia, Sabaretnam Mayilvagnan, Gyan Chand, Gaurav Agarwal, Amit Agarwal & Saroj Kanta Mishra

Abstract:

Background

There is limited experience in managing pediatric primary hyperparathyroidism (PHPT). The aim of this study was to analyze the clinical presentation and outcome of surgery in children with PHPT managed at a tertiary referral center.

 

Methods

This retrospective study (September 1989–August 2019) consisted of 35 pediatric PHPT patients (< 18 years) who underwent parathyroidectomy. Clinico-pathologic profile and outcome were noted.

 

Results

The mean age of cohort was 15.2±2.9 years and girls outnumbered boys (M:F = 1:1.9). Familial and symptomatic disease was noted in 8.5 and 94.3% cases, respectively. Skeletal manifestations (83%) were the commonest followed by renal (29%). Fifty-four percent children had skeletal fractures, and 23% were bed-ridden. Among rare manifestations, hypercalcemic crisis, recurrent pancreatitis and stigmata of rickets were observed in 2.8, 11.4 and 14.2% children, respectively. Mean calcium concentration was 12.1 ± 2.0 mg/dl and PTH 91.8 ± 66.5 pmol/L. The sensitivity of preoperative imaging in parathyroid localization was 91.4%. Minimally invasive parathyroidectomy (MIP) was performed in 40% cases. Parathyroid adenoma was observed in 91.4% patients, whereas remaining had hyperplasia. Thirty-four percent suffered from Hungry bone syndrome in postoperative period. The cure rate following primary surgery was 97%. One child with persistent PHPT had successful re-operation. Median follow-up was 5 (1–17) years, and no recurrence or familial disease was revealed during this period.

 

Conclusion

Majority of pediatric patients present with symptomatic PHPT. Despite relatively high incidence of familial disease select pediatric patients can undergo successful MIP.

URL: https://rdcu.be/cd3o5

 


Systematic Reviews and Meta-Analyses: Outcomes of Laparoscopic Splenectomy for Treatment of Splenomegaly: A Systematic Review and Meta-analysis

 

Author list:

María Rita Rodríguez-Luna, Carmen Balagué, Sonia Fernández-Ananín, Ramon Vilallonga & Eduardo María Targarona Soler

 

Abstract:

Objectives

To review the evidence regarding the outcomes of laparoscopic techniques in cases of splenomegaly.

 

Background

Endoscopic approaches such as laparoscopic, hand-assisted laparoscopic, and robotic surgery are commonly used for splenectomy, but the advantages in cases of splenomegaly are controversial.

 

Review methods

We conducted a systematic review using PRISMA guidelines. PubMed/MEDLINE, ScienceDirect, Scopus, Cochrane Library, and Web of Science were searched up to February 2020.

 

Results

Nineteen studies were included for meta-analysis. In relation to laparoscopic splenectomy (LS) versus open splenectomy (OS), 12 studies revealed a significant reduction in length of hospital stay (LOS) of 3.3 days (p = <0.01) in the LS subgroup. Operative time was higher by 44.4 min (p < 0.01) in the LS group. Blood loss was higher in OS 146.2 cc (p = <0.01). No differences were found regarding morbimortality. The global conversion rate was 19.56%. Five studies compared LS and hand-assisted laparosocpic splenectomy (HALS), but no differences were observed in LOS, blood loss, or complications. HALS had a significantly reduced conversion rate (p < 0.01). In two studies that compared HALS and OS (n = 66), HALS showed a decrease in LOS of 4.5 days (p < 0.01) and increase of 44 min in operative time (p < 0.01), while OS had a significantly higher blood loss of 448 cc (p = 0.01). No differences were found in the complication rate.

 

Conclusion

LS is a safe approach for splenomegaly, with clear clinical benefits. HALS has a lower conversion rate. Higher-quality confirmatory trials with standardized splenomegaly grading are needed before definitive recommendations can be provided.

URL:  https://rdcu.be/cd3pf

 


Systematic Reviews and Meta-Analyses: The Impact of Cirrhosis on Pancreatic Cancer Surgery: A Systematic Review and Meta-Analysis

 

Author list:

Dimitrios Schizas, Spyridon Peppas, Stefanos Giannopoulos, Vasiliki Lagopoulou, Konstantinos S. Mylonas, Spyridon Giannopoulos, Dimitrios Moris, Evangelos Felekouras & Konstantinos Toutouzas

 

Abstract:

Background

Cirrhosis has been considered a contraindication to major abdominal surgeries, due to increased risk for postoperative morbidity and mortality. The aim of this study was to assess the safety of pancreatectomy in cirrhotic versus non-cirrhotic patients.

 

Methods

The present systematic review and meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. All meta-analyses were performed using the random effects model.

 

Results

Eight studies were eventually included, enrolling 1229 patients (cirrhotics: 722; and Child–Pugh A: 593; Child–Pugh B/C: 129) who underwent surgery for pancreatic cancer. The overall postoperative morbidity rate was 66% (51%–80%). Infections (26%) and ascites formation/worsening (23%) were the most common postoperative complications, followed by anastomotic leak/fistula (17%). Non-cirrhotic patients were less likely to suffer from anastomotic leak/fistula (OR: 0.39; 95% CI: 0.23–0.65) and infections (OR: 0.41; 95% CI: 0.25–0.67). Postoperative mortality rate was statistically significantly lower in non-cirrhotic versus cirrhotic patients (OR: 0.18; 95% CI:0.18–0.39). The odds ratios of 1 year (OR: 0.62; 95% CI: 0.30–1.30), 2 year (OR: 0.67; 95% CI: 0.25–1.83) and 3 year all-cause mortality (OR: 0.32; 95% CI: 20.03–2.99) were not significantly different between cirrhotic versus non-cirrhotic patients.

 

Conclusion

This study demonstrated that non-cirrhotic patients were less likely to undergo any type of re-intervention and had statistically significant lower postoperative mortality rates compared to patients with cirrhosis.

 

URL:  https://rdcu.be/cd3pA

 

 


 

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