Featured Articles in Jan 2022

Burnout Among Surgeons in the UK During the COVID-19 Pandemic: A Cohort Study

 

Author list:  Jonathan Houdmont, Prita Daliya, Elena Theophilidou, Alfred Adiamah, Juliet Hassard, and Dileep N. Lobo on behalf of the East Midlands Surgical Academic Network (EMSAN) Burnout Study Group

Abstract:

Background

Surgeon burnout has implications for patient safety and workforce sustainability. The aim of this study was to establish the prevalence of burnout among surgeons in the UK during the COVID-19 pandemic.

Methods

This cross-sectional online survey was set in the UK National Health Service and involved 601 surgeons across the UK of all specialities and grades. Participants completed the Maslach Burnout Inventory and a bespoke questionnaire. Outcome measures included emotional exhaustion, depersonalisation and low personal accomplishment, as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS).

Results

A total of 142 surgeons reported having contracted COVID-19. Burnout prevalence was particularly high in the emotional exhaustion (57%) and depersonalisation (50%) domains, while lower on the low personal accomplishment domain (15%). Burnout prevalence was unrelated to COVID-19 status; however, the greater the perceived impact of COVID-19 on work, the higher the prevalence of emotional exhaustion and depersonalisation. Degree of worry about contracting COVID-19 oneself and degree of worry about family and friends contacting COVID-19 was positively associated with prevalence on all three burnout domains. Across all three domains, burnout prevalence was exceptionally high in the Core Trainee 1–2 and Specialty Trainee 1–2 grades.

Conclusions

These findings highlight potential undesirable implications for patient safety arising from surgeon burnout. Moreover, there is a need for ongoing monitoring in addition to an enhanced focus on mental health self-care in surgeon training and the provision of accessible and confidential support for practising surgeons.

Free link: https://rdcu.be/cDl0y

 


The Role of Telemedicine in Surgical Specialties During the COVID-19 Pandemic: A Scoping Review

 

Author list:  Mahir Gachabayov, Lulejeta A. Latifi, Afshin Parsikia & Rifat Latifi

Abstract:

Background

The objective of this study was to evaluate the current body of evidence on the use of telemedicine in surgical subspecialties during the COVID-19 pandemic.

Methods

This was a scoping review conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR). MEDLINE via Ovid, PubMed, and EMBASE were systematically searched for any reports discussing telemedicine use in surgery and surgical specialties during the first period (February 2020–August 8, 2020) and second 6-month period (August 9–March 4, 2021) of the COVID-19 pandemic.

Results

Of 466 articles screened through full text, 277 articles were included for possible qualitative and/or quantitative data synthesis. The majority of publications in the first 6 months were in orthopedic surgery, followed by general surgery and neurosurgery, whereas in the second 6 months of COVID-19 pandemic, urology and neurosurgery were the most productive, followed by transplant and plastic surgery. Most publications in the first 6 months were opinion papers (80%), which decreased to 33% in the second 6 months. The role of telemedicine in different aspects of surgical care and surgical education was summarized stratifying by specialty.

Conclusion

Telemedicine has increased access to care of surgical patients during the COVID-19 pandemic, but whether this practice will continue post-pandemic remains unknown.

Free link: https://rdcu.be/cDl02

 


ERAS: Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery

Author list:  Paul Andrew Drakeford, Shu Qi Tham, Jia Li Kwek, Vera Lim, Chien Joo Lim, Kwang Yeong How & Olle Ljungqvist

Abstract:

Background

We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS).

Methods

This is a retrospective case–control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI.

Results

A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1—11.2%, stage 2—2.0%, stage 3—0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0–17.0] days vs 6.0 [4.0–8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00–14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48–4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10 µmol/l; 95% CI, 1.03–1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06–0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22–1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63–11.70; P < 0.001).

Conclusions

Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

Free link: https://rdcu.be/cDl1d


Supervised Immediate Postoperative Mobilization After Elective Colorectal Surgery: A Feasibility Study

 

 

Author list:  Rose-Marie W. Thörn, Jan Stepniewski, Hans Hjelmqvist, Anette Forsberg, Rebecca Ahlstrand & Olle Ljungqvist

Abstract:

Background

Early mobilization is a significant part of the ERAS® Society guidelines, in which patients are recommended to spend 2 h out of bed on the day of surgery. However, it is not yet known how early patients can safely be mobilized after completion of colorectal surgery. The aim of this study was to evaluate the feasibility, and safety of providing almost immediate structured supervised mobilization starting 30 min post-surgery at the postoperative anesthesia care unit (PACU), and to describe reactions to this approach.

Methods

This feasibility study includes 42 patients aged ≥18 years who received elective colorectal surgery at Örebro University Hospital. They underwent a structured mobilization performed by a specialized physiotherapist using a modified Surgical ICU Optimal Mobilization Score (SOMS). SOMS determines the level of mobilization at four levels from no activity to ambulating. Mobilization was considered successful at SOMS ≥ 2, corresponding to sitting on the edge of the bed as a proxy of sitting in a chair due to lack of space.

Results

In all, 71% (n = 30) of the patients reached their highest level of mobilization between the second and third hour of arrival in the PACU. Before discharge to the ward, 43% (n = 18) could stand at the edge of the bed and 38% (n = 16) could ambulate. Symptoms that delayed advancement of mobilization were pain, somnolence, hypotension, nausea, and patient refusal. No serious adverse events occurred.

Conclusions

Supervised mobilization is feasible and can safely be initiated in the immediate postoperative care after colorectal surgery.

Trial registration Clinical trials.gov identifier: NTC03357497.

Free link: https://rdcu.be/cDl1l

 


Penetrating Colon Trauma—the Effect of Injury Location on Outcomes

 

Author list:  G. V. Oosthuizen, S. R. Čačala, V. Y. Kong, D. Couch, J. Buitendag, S. Variawa, N. Allen & D. L. Clarke

Abstract:

Background

There is limited evidence to suggest that the more distal a penetrating colonic injury, the poorer its expected outcome, prompting consideration of diversion rather than anastomosis when faced with left colonic injury. The clinical outcomes of penetrating colonic trauma in relation to their anatomical location within the colon were reviewed.

Methods

A review was performed over eight years (2012—2020) of all patients over 18 years who had sustained penetrating colon injury and presented to our trauma centre in South Africa. Direct comparison was made between right colon vs left colon injuries.

Results

A total of 450 patients were included; right colon: 260, left colon: 190. Gunshots predominated in the right colon, and the PATI was higher in this group. There were minimal differences in admission physiology and blood gas parameters between groups, but higher damage control surgery and ICU admission rates for the right colon group. There were similar rates of primary repair, anastomosis, and stoma between groups. Leak rates were no different between the two groups, and although overall complication rates were higher for the right colon, there was no difference with regard to gastro-intestinal and other complications, nor for mortality. While regression analysis did identify PATI to be a risk factor for overall complications and mortality, it failed to do so for anastomotic leak.

Conclusion

Our study did not demonstrate any difference in anastomotic leak rates or mortality between right vs left colonic injury. We recommend that all colonic injuries should be treated on their own merit, balanced against the patient’s condition, regardless of anatomical location within the colon.

Free link: https://rdcu.be/cDl1X

 


Intraoperative Indocyanine Green Angiography of Parathyroid Glands and the Prevention of Post-Thyroidectomy Hypocalcemia

 

 

Author list:  Pablo Moreno Llorente, Arantxa García Barrasa, José Manuel Francos Martínez, Marta Alberich Prats & Mireia Pascua Solé

Abstract:

Background

We compared the reliability of indocyanine green (ICG) angiography and intraoperative PTH levels for predicting early post-thyroidectomy hypocalcemia.

Methods

Prospective study of 94 patients (71% women, mean age 53.7 years) undergoing total thyroidectomy. An ICG score of 2 (white) indicated a well-vascularized gland. PTH preoperative levels—PTH postresection levels divided by preoperative PTH × 100 was used to determine the PTH decline percentage. A decrease of at least 62.5% or <17.1 pg/mL in ioPTH was the criterion for predicting hypocalcemia.

Results

At surgery, the four parathyroid glands were identified in 50 (53.2%) patients and <4 glands in 44. Calcium supplements were needed by 22 patients (23.4%) postoperatively, 11 patients in each group of 4 and <4 parathyroid glands identified. The diagnostic accuracy of ICG angiography (0.883, 95% confidence interval [CI] 0.800–0.940) and ioPTH (0.862, 95% CI 0.775–0.92) was similar. When all four parathyroid glands were identified, ICG angiography showed a slightly higher diagnostic accuracy, specificity and positive predictive than ioPTH levels, but when < 4 glands were identified, the ioPTH showed a slightly higher diagnostic accuracy, specificity and positive predictive value. Differences were not statistically significant for any of the comparisons.

Conclusions

The presence of one well-perfused parathyroid gland (ICG score 2) using ICG angiography or ioPTH decline, measured before and after completion of thyroid surgery, is both reliable methods in prediction of early post-thyroidectomy hypocalcemia independently of the number of glands identified intraoperatively.

Free link: https://rdcu.be/cDl2d

 


We Asked the Experts: The Promises and Challenges of Surgical Telehealth in Low Resourced Settings

 

Author list:  Phoebe Miller, Eyitayo Owolabi & Kathryn Chu

Abstract: NA

Free link: https://rdcu.be/cDl2u

 


My First Paper: Propensity-Score Matched Analyses Comparing Clinical Outcomes of Minimally Invasive Versus Open Distal Pancreatectomies

 

 

Author list:  Jaivikash Raghupathy, Chuan-Yaw Lee, Sarah K. W. Huan, Ye-Xin Koh, Ek-Khoon Tan, Jin-Yao Teo, Peng-Chung Cheow, London L. P. J. Ooi, Alexander Y. F. Chung, Chung-Yip Chan & Brian K. P. Goh

Abstract:

Background

Minimally invasive distal pancreatectomy (MIDP) is being adopted increasingly worldwide. This study aimed to compare the short-term outcomes of patients who underwent MIDP versus open distal pancreatectomy (ODP).

Methods

A retrospective review of all patients who underwent a DP in our institution between 2005 and 2019 was performed. Propensity score matching based on relevant baseline factors was used to match patients in the ODP and MIDP groups in a 1:1 manner. Outcomes reported include operative duration, blood loss, postoperative length of stay, morbidity, mortality, postoperative pancreatic fistula rates, reoperation and readmission.

Results

In total, 444 patients were included in this study. Of 122 MIDP patients, 112 (91.8%) could be matched. After matching, the median operating time for MIDP was significantly longer than ODP [260 min (200–346.3) vs 180 (135–232.5), p < 0.001], while postoperative stay for MIDP was significantly shorter [median 6 days (5–8) versus 7 days (6–9), p = 0.015]. There were no significant differences noted in any of the other outcomes measured. Over time, we observed a decrease in the operation times of MIDP performed at our institution.

Conclusion

Adoption of MIDP offers advantages over ODP in terms of a shorter postoperative hospital stay, without an increase in morbidity and/or mortality but at the expense of a longer operation time.

Free link: https://rdcu.be/cDl2H

 


Systematic Reviews and Meta-Analyses: (Neo)adjuvant Chemoradiotherapy is Beneficial to the Long-term Survival of Locally Advanced Esophageal Squamous Cell Carcinoma: A Network Meta-analysis

Author list:  Zixian Jin, Dong Chen, Meng Chen, Chunguo Wang, Bo Zhang, Jian Zhang, Chengchu Zhu & Jianfei Shen

Abstract:

Purpose

To determine the most effective and safest treatment mode for locally advanced resectable esophageal squamous cell carcinoma through a network meta-analysis.

Method

A Bayesian model was used for a network meta-analysis comparing the efficacy and safety of surgery alone, neoadjuvant therapy, and adjuvant therapy.

 

Results

Thirty clinical studies, including thirty-one articles, 4866 patients, were analyzed. Overall survival rate: Adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy were significantly advantageous over surgery alone [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.57–0.93; HR 0.75, 95%CI 0.65–0.86]. There was no statistically significant difference between adjuvant chemoradiotherapy and neoadjuvant chemoradiotherapy [HR 0.97, 95%CI 0.75–1.28]. Disease-free survival rate: Compared with surgery alone, neoadjuvant chemoradiotherapy had significant benefits [HR 0.65, 95%CI 0.53–0.78]; adjuvant chemoradiotherapy had similar, but not significant benefits [HR 0.7, 0.95%CI 0.45–1.06]. The difference between neoadjuvant chemoradiotherapy and adjuvant chemoradiotherapy was also not statistically significant [HR 0.94, 0.95%CI 0.61–1.43]. Surgery after neoadjuvant chemoradiotherapy: The R0 resection rate was significantly improved [relative risk (RR) 0.25, 95%CI 0.07–0.86], but the overall postoperative morbidity rate and 30-day postoperative mortality rate tended to increase [RR 1.27, 95%CI 0.8–2.01; RR 1.59, 95%CI 0.7–3.22]. Neither neoadjuvant chemotherapy nor neoadjuvant radiotherapy significantly altered the surgical safety or R0 resection rate.

Conclusion

Both neoadjuvant chemoradiotherapy and adjuvant chemoradiotherapy appear to be the best supplements to surgery for locally advanced resectable esophageal squamous cell carcinoma.

Free link: https://rdcu.be/cDl2Z


Esophageal Duplication Cysts in 97 Adult Patients: A Systematic Review

Author list:  Mauricio Gonzalez-Urquijo, David Eugenio Hinojosa-Gonzalez, Diana Paola Padilla-Armendariz, Jorge Alberto Saldaña-Rodriguez, Adolfo Leyva-Alvizo, Mario Rodarte-Shade & Javier Rojas-Mendez

Abstract:

Background

Esophageal duplication cysts are a rare congenital cystic malformation from faulty intrauterine recanalization of the esophagus during the 4-8th weeks of development. They account for 20% of all gastrointestinal duplication cysts and commonly involve the distal esophagus. Presenting symptoms may be related to size and location.

Materials and Methods

Following the PRISMA guidelines, a systematic review was performed by searching published literature in various databases. Data from 97 reported case reports were pooled to present a descriptive and statistical analysis.

Results

Patient population was composed of 51(52.5%) males and 46 (47.5%) females, and mean ages was 42.3 years (18–77). Distal cysts were the most prevalent. Seventy-nine (81.4%) patients were symptomatic; common symptoms included dysphagia, chest pain, cough and weight loss. Fifteen (15.5%) patients were treated conservatively and 75 (84.5%) by surgical treatment, among them thoracotomy in 30 (30.9%) patients and VATS in 17 (17.5%) patients. Mean length of hospital stay was 8.6 days (range: 1–26 days). One fatality was registered. Location, unlike size, was not found to influence presenting symptoms or treatment employed. Frequency of conservative treatment was not significantly different between symptomatic and asymptomatic patients. Open approaches were associated with longer stays than their minimally invasive counterparts.

Conclusion

Esophageal duplication cysts remain rare in adults and are frequently located in the distal esophagus. Larger cysts are more likely to cause symptoms. Various surgical techniques may successfully be employed in the treatment of this pathology. Minimally invasive procedures have a shorter hospital stay.

Free link:  https://rdcu.be/cDl3b


 

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