Editorial
2020 in Review: New Researchers (My First Paper) and Topic Experts (We Asked the Experts) from Across the Globe
Author list:
Roman, S.
Abstract: no abstract
URL: https://rdcu.be/cblJp
COVID19
Different Crises, Different Patterns of Trauma. The Impact of a Social Crisis and the COVID-19 Health Pandemic on a High Violence Area.
Author list:
Ramos Perkis, J.P., Achurra Tirado, P., Raykar, N. et al.
Abstract:
Backgound
Santiago, Chile underwent two separate periods of crisis over the past year. The first period, the ‘social crisis,’ extended over thirteen weeks in late 2019 into early 2020 due to protests over income inequality and the government response to social unrest. The second period, the ‘health crisis,’ began in March 2020 with Chile’s first case of COVID-19 and escalated rapidly to include ‘stay at home orders,’ traffic restrictions, and the shuttering of most businesses. We wished to evaluate the impact of these crisis periods on trauma epidemiology.
Methods
We performed a retrospective review of the South-East Metropolitan Health Service Trauma Registry. Trauma admissions, operative volume, and in-hospital mortality were evaluated during the crisis period and the year prior.
Results
The social crisis saw increased levels of trauma, both blunt and penetrating, relative to the time period immediately preceding. The health crisis saw an increase in penetrating trauma with a concomitant decline in blunt trauma. Both crisis periods had decreased levels of trauma, overall, compared to the year prior. There were no statistically significant differences in in-hospital trauma mortality.
Conclusion
Different crises may have different patterns of trauma. Crisis periods that include extended periods of lockdown and curfew may lead to increasing penetrating trauma volume. Governments and health officials should anticipate the aggregate impact of these measures on public health and develop strategies to actively mitigate them.
Level of evidence
III
Impact of the COVID-19 Pandemic on Surgical Residency Training: Perspective from a Low-Middle Income Country
Article Title
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Did the COVID-19 Pandemic Cause a Delay in the Diagnosis of Acute Appendicitis?
Author list:
Turanli, S., Kiziltan, G.
Abstract:
Background
Appendectomy for acute appendicitis remains one of the most common surgical procedures. This study aims to assess the clinical presentation and delays in diagnosing acute appendicitis during the COVID-19 pandemic.
Methods
We evaluated data of all adult patients who underwent an appendectomy at our hospital between June 1, 2019 and June 1, 2020. Demographic data, admission type to the emergency room, radiological findings, pathological findings, and hospitalization time were noted. Patients were divided into four groups of 3-month periods, pre (Groups 5, 4, 3, 2) and during the pandemic (Group 1). Hospitalization time and perforation status of each group were compared. The hospital admission type and their effect on perforation were also evaluated.
Results
Two hundred and fourteen patients were included; 135 patients were male, and 57 were female. The median age was 39 years. In Group 1 (pandemic period), 28.8% of patients were referred to us from pandemic hospitals. The median hospitalization time was 7.3 h before pandemics (Group 2–5), 5 h in the pandemic period (Group 1). Perforation rates were 27.8% in Group 1, 23.3% in Group 2, 16.3% in Group 3, 14.0% in Group 4, and 18.6% in Group 5 (0 = 0.58). There was no difference in the patients in Group 1 in the rate of perforated appendicitis in patients who were referred from other pandemic hospitals (29.4) and those admitted via our own emergency room (16.6%) (p = 0.27) during the pandemic period.
Conclusion
We did not observe any clear increase in the diagnosis of perforated appendicitis during the pandemic period, even in patients who were transferred from other hospitals.
ERAS
Impact of Multidisciplinary Audit of Enhanced Recovery After Surgery (ERAS)® Programs at a Single Institution
Author list:
Pickens, R.C., Cochran, A.R., Lyman, W.B. et al.
Abstract:
Background
As Enhanced Recovery After Surgery (ERAS®) programs expand across numerous subspecialties, growth and sustainability on a system level becomes increasingly important and may benefit from reporting multidisciplinary and financial data. However, the literature on multidisciplinary outcome analysis in ERAS is sparse. This study aims to demonstrate the impact of multidisciplinary ERAS auditing in a hospital system. Additionally, we describe developing a financial metric for use in gaining support for system-wide ERAS adoption and sustainability.
Methods
Data from HPB, colorectal and urology ERAS programs at a single institution were analyzed from a prospective ERAS Interactive Audit System (EIAS) database from September 2015 to June 2019. Clinical 30-day outcomes for the ERAS cohort (n = 1374) were compared to the EIAS pre-ERAS control (n = 311). Association between improved ERAS compliance and improved outcomes were also assessed for the ERAS cohort. The potential multidisciplinary financial impact was estimated from hospital bed charges.
Results
Multidisciplinary auditing demonstrated a significant reduction in postoperative length of stay (LOS) (1.5 days, p < 0.001) for ERAS patients in aggregate and improved ERAS compliance was associated with reduced LOS (coefficient − 0.04, p = 0.004). Improved ERAS compliance in aggregate also significantly associated with improved 30-day survival (odds ratio 1.04, p = 0.001). Multidisciplinary analysis also demonstrated a potential financial impact of 44% savings (p < 0.001) by reducing hospital bed charges across all specialties.
Conclusions
Multidisciplinary auditing of ERAS programs may improve ERAS program support and expansion. Analysis across subspecialties demonstrated associations between improved ERAS compliance and postoperative LOS as well as 30-day survival, and further suggested a substantial combined financial impact.
Symposia
Provider–patient Language Discordance and Cancer Operations: Outcomes from a Single Center Linked to a State Vital Statistics Registry.
Author list –
Feeney, T., Park, C., Godley, F. et al.
Abstract:
Introduction
Patterns of worldwide immigration have resulted in high rates of discordance between medical providers and the patients they treat. For example, in the USA, 25 million individuals in the USA self-identified that they speak English less than “very well.” Previous studies have generated mixed results regarding differences in postoperative outcomes between English proficient (EP) and limited English proficient (LEP) patients. Our objective was to determine whether a difference in outcomes exists for non-English-speaking patients compared to English-speaking patients after operations commonly performed to treat cancer.
Study design
A retrospective cohort study was performed in an urban, safety net and tertiary referral medical center over a five-year period. Adult patients undergoing cancer operations were stratified as EP and LEP. We evaluated 30-day revisit to the ED, length of stay (LOS), long-term all-cause mortality, and any major complication on index admission. Regression was used to adjust for baseline comorbidities, case risk, and socioeconomic factors.
Results
A total of 2467 patients were included. There was no difference in case risk between language groups, but EP had a larger proportion of high comorbidity scores. Patients in the non-English group were more likely to be uninsured/self-pay and live in neighborhoods with lower median income. After adjustment, we found no difference in long-term mortality [hazard ratio: 0.87 (95% CI 0.52–1.45)]. LEP patients had the same LOS compared to primary EP patients with an IRR of 0.99 (95% CI 0.88–1.10). There was no difference in the odds of revisit to hospital for LEP versus EP, with an OR of 1.08, 95% CI [0.75–1.53] and no difference in major complication (OR 0.76 (95% CI 0.39–1.45).
Conclusions
We found no association between language and outcomes after cancer operations. This lack of difference may reflect local efficacy at treating non-English-speaking patients, and health systems with fewer services for LEP patients might show different results.
URL: currently not available
Systematic Reviews and Meta-Analyses:
Community- and Hospital-Acquired Infections in Surgical patients at a Tertiary Referral Hospital in Rwanda
Author list –
Muvunyi, V., Mpirimbanyi, C., Katabogama, J.B. et al.
Abstract:
Background
Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-PE) are increasing in globally. The aim of this study was to compare community-acquired infections (CAIs) and hospital-acquired infections (HAIs) and determine the rate of third-generation cephalosporin resistance and ESBL-PE at a tertiary referral hospital in Rwanda.
Methods
This was a cross-sectional study of Rwandan acute care surgery patients with infection. Samples were processed for culture and susceptibility patterns using Kirby-Bauer disk diffusion method. Third-generation cephalosporin resistance and ESBL-PE were compared in patients with CAI versus HAI.
Results
Over 14 months, 220 samples were collected from 191 patients: 116 (62%) patients had CAI, 59 (32%) had HAI, and 12 (6%) had both CAI and HAI. Most (n = 178, 94%) patients were started on antibiotics with third-generation cephalosporins (ceftriaxone n = 109, 57%; cefotaxime n = 52, 27%) and metronidazole (n = 155, 81%) commonly given. Commonly isolated organisms included Escherichia coli (n = 62, 42%), Staphylococcus aureus (n = 27, 18%), and Klebsiella spp. (n = 22, 15%). Overall, 67 of 113 isolates tested had resistance to third-generation cephalosporins, with higher resistance seen in HAI compared with CAI (74% vs 46%, p value = 0.002). Overall, 47 of 89 (53%) isolates were ESBL-PE with higher rates in HAI compared with CAI (73% vs 38%, p value = 0.001).
Conclusions
There is broad and prolonged use of third-generation cephalosporins despite high resistance rates. ESBL-PE are high in Rwandan surgical patients with higher rates in HAI compared with CAIs. Infection prevention practices and antibiotic stewardship are critical to reduce infection rates with resistant organisms in a low-resource setting.
URL: currently not available
Systematic Reviews and Meta-Analyses
What to Propose After Failed Adjustable Gastric Banding: One- or Two-step Procedure?
Author list –
Marion, Y., Eid, Y., Menahem, B. et al.
Abstract:
Background
Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) can be proposed in case of failed laparoscopic adjustable gastric band (LAGB). The main question is whether the revisional procedure is carried out in one or two stages.
Objective
Postoperative outcomes between the one-step approach and the two-step approach of conversion of failed LAGB to RYGB or SG were, respectively, compared.
Methods
A systematic review of the literature published until June 2019 was conducted. All studies comparing one-step and two-step approaches after failed LAGB were included. Primary outcomes include both mortality and morbidity at 30 days postoperatively according to Dindo–Clavien classification. Among the studies included, a random effect model was used with Review Manager 5.3 (Cochrane Collaboration, Oxford, UK).
Results
A total of 3895 patients had conversion of failed LAGB to RYGB (n = 3214) or SG (n = 681), respectively. The conversion was carried out in one-step (n = 2767) or two-step (n = 1128) approaches. Meta-analysis did not show statistical difference for overall morbidity rate (OR = 1.01, 95%CI = 0.78–1.30, p = 0.96) whether it is for SG (OR = 1.25, 95%CI = 0.73–2.14, p = 0.42) or RYGB (OR = 0.94, 95%CI = 0.71–1.26, p = 0.69) and for major postoperative morbidity (OR = 0.96, 95%CI = 0.59–1.56, p = 0.87) whether it is for SG (OR = 0.66, 95%CI = 0.22–1.97, p = 0.46) or RYGB (OR = 1.05, 95%CI = 0.61–1.81, p = 0.86). Moreover, there was no statistical difference for specific morbidity rate including reoperation, leak, abscess, postoperative bleeding, and late postoperative complications.
Limitations
Given the retrospective nature of the studies, these results should be interpreted with caution.
Conclusion
This updated meta-analysis suggests that conversion of failed LAGB to RYGB or SG can be safely performed in one-step or two-step approaches.
Esophageal Lipoma and Liposarcoma: A Systematic Review
Author list:
Ferrari, D., Bernardi, D., Siboni, S. et al.
Abstract:
Background
Esophageal lipomatous tumors, also reported as fibrovascular polyp, fibrolipoma, angiolipoma, and liposarcoma, account for less than 1% of all benign mesenchymal submucosal tumors of the esophagus. Clinical presentation and therapy may differ based on location, size, and morphology. A comprehensive and updated systematic review of the literature is lacking.
Methods
A systematic review of the literature was performed according to PRISMA guidelines. Pubmed, Embase, Cochrane, and Medline databases were consulted using MESH keywords. Non-English written articles and abstracts were excluded. Sex, age, symptoms at presentation, diagnosis, tumor location and size, surgical approach and technique of excision, pathology, and morphology were extracted and recorded in an electronic database.
Results
Sixty-seven studies for a total of 239 patients with esophageal lipoma or liposarcoma were included in the qualitative analysis. Among 176 patients with benign lipoma, the median age was 55. The main symptoms were dysphagia (64.2%), transoral polyp regurgitation (32.4%), and globus sensation (22.7%). The majority of lipomas (85.7%) were intraluminal polyps, with a stalk originating from the upper esophagus. Overall, 165 patients underwent excision of the mass through open surgery (65.5%), endoscopy (27.9%), or laparoscopy/thoracoscopy (3.6%). Only 5 (3%) of patients required esophagectomy. Of the 11 untreated patients with an intraluminal polyp, 7 died from asphyxia. Overall, liposarcoma was diagnosed in 63 patients, and 12 (19%) underwent esophagectomy.
Conclusion
Esophageal lipomatous tumors are rare but potentially lethal when are intraluminal and originate from the cervical esophagus. Modern radiological imaging has improved diagnostic accuracy. Minimally invasive transoral and laparoscopic/thoracoscopic techniques represent the therapeutic approach of choice.
