Featured Articles in Jan 2023

Editorial: Faith in Things Unseen

 

 

 

Author -- John G. Meara

NO ABSTRACT

FREE LINK - https://rdcu.be/c1YT1

 


ISS: War, Politics, Pandemic, and a Failed Assassination: 117 Years of World Congresses of Surgery

 

 

 

 

Author - John G. Hunter

NO ABSTRACT

FREE LINK - https://rdcu.be/c1YUa

 


Inspirational Women in Surgery: Dr. Jane Fualal Odubu, Uganda

 

Authors - Cathy Kilyewala & Doruk Ozgediz

NO ABSTRACT

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ERAS: Guidelines for Perioperative Care for Liver Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations 2022

 

 

 

Authors - Gaëtan-Romain Joliat, Kosuke Kobayashi, Kiyoshi Hasegawa, John-Edwin Thomson, Robert Padbury, Michael Scott, Raffaele Brustia, Olivier Scatton, Hop S. Tran Cao, Jean-Nicolas Vauthey, Selim Dincler, Pierre-Alain Clavien, Stephen J. Wigmore, Nicolas Demartines & Emmanuel Melloul

 

 

Abstract

Background

Enhanced Recovery After Surgery (ERAS) has been widely applied in liver surgery since the publication of the first ERAS guidelines in 2016. The aim of the present article was to update the ERAS guidelines in liver surgery using a modified Delphi method based on a systematic review of the literature.

 

Methods

A systematic literature review was performed using MEDLINE/PubMed, Embase, and the Cochrane Library. A modified Delphi method including 15 international experts was used. Consensus was judged to be reached when >80% of the experts agreed on the recommended items. Recommendations were based on the Grading of Recommendations, Assessment, Development and Evaluations system.

 

Results

A total of 7541 manuscripts were screened, and 240 articles were finally included. Twenty-five recommendation items were elaborated. All of them obtained consensus (>80% agreement) after 3 Delphi rounds. Nine items (36%) had a high level of evidence and 16 (64%) a strong recommendation grade. Compared to the first ERAS guidelines published, 3 novel items were introduced: prehabilitation in high-risk patients, preoperative biliary drainage in cholestatic liver, and preoperative smoking and alcohol cessation at least 4 weeks before hepatectomy.

 

Conclusions

 These guidelines based on the best available evidence allow standardization of the perioperative management of patients undergoing liver surgery. Specific studies on hepatectomy in cirrhotic patients following an ERAS program are still needed.

 

 

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We Asked the Experts: Modified Mesh-Mediated Fascial Traction in the Management of the Open Abdomen

 

 

Author - Rodney Jacobs

 

NO ABSTRACT.

A visual abstract for this article has been requested.  Unknown when it will be completed.

 

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Postoperative Complications and Outcome After Emergency Laparotomy

 

 

Authors - Aura T. Ylimartimo, Juho Nurkkala, Marjo Koskela, Sanna Lahtinen, Timo Kaakinen, Merja Vakkala, Siiri Hietanen & Janne Liisanantti

 

A visual abstract for this article has been requested.  Unknown when it will be completed.

 

 

Abstract

Background

Emergency laparotomy (EL) is a common urgent surgical procedure with high risk for postoperative complications. Complications impair the prognosis and prolong the hospital stay. This study explored the incidence and distribution of complications and their impact on short-term mortality after EL.

 

Methods

This was a retrospective single-center register-based cohort study of 674 adults undergoing midline EL between May 2015 and December 2017. The primary outcome was operation-related or medical complication after EL. The secondary outcome was mortality in 90-day follow-up. Multivariate logistic regression analyses were used to identify independent risk factors for complications.

 

Results

A total of 389 (58%) patients developed complications after EL, including 215 (32%) patients with operation-related complications and 361 (54%) patients with medical complications. Most of the complications were Clavien-Dindo classification type 4b (28%) and type 2 (22%). Operation-related complications occurred later compared to medical complications. Respiratory complications were the most common medical complications, and infections were the most common operation-related complications. The 30- and 90-day mortalities were higher in both the medical (17.2%, 26.2%) and operation-related complication groups (13.5%, 24.2%) compared to patients without complications (10.5% and 4.8%, 14.8% and 8.0%). Low albumin, high surgical urgency, excessive alcohol consumption and medical complications were associated with operation-related complications. Older age, high ASA class and operation-related complications were associated with medical complications.

 

Conclusions

This study demonstrated that EL is associated with a high risk of complications and poor short-term outcome. Complications impair the prognosis regardless of which kind of EL is in question.

 

FREE LINK – [already OA] - https://rdcu.be/c1YWO

 


Timing of Elective Cholecystectomy After Acute Cholecystitis

 

Authors - Agnieszka Popowicz, Lars Enochsson & Gabriel Sandblom

A visual abstract for this article has been requested.  Unknown when it will be completed.

 

 

Abstract

Background

Acute cholecystectomy is standard treatment for acute cholecystitis. However, many patients are still treated conservatively and undergo delayed elective surgery. The aim of this study was to determine the ideal time to perform an elective cholecystectomy after acute cholecystitis.

 

Methods

All patients treated for acute cholecystitis in Sweden between 2006 and 2013 were identified through the Swedish Patient Register. This cohort was cross-linked with the Swedish Register for Gallstone Surgery, GallRiks, where information on surgical outcome was retrieved. The impact of the time interval after discharge from hospital to elective surgery was analysed by multivariate logistic regression adjusting for gender and age.

 

Results

After exclusion of patients not subjected to surgery, not registered in GallRiks and patients treated with acute cholecystectomy, 8532 remained. This cohort was divided into six-time categories. Using the first time interval < 11 days from discharge to elective surgery as the reference category the chance of completing surgery with a minimally invasive technique was increased for all categories (p < 0.05). The risk for perioperative complication and cystic duct leakage was reduced if surgery was undertaken > 30 days after discharge (both p < 0.05). The risk for bile duct injury was significantly increased if the procedure was undertaken > 365 days after discharge (p = 0.030). The chance of completing the procedure within 100 min was not affected by time.

 

Conclusion

For patients undergoing elective cholecystectomy after acute cholecystitis, the safety of the procedure increases if surgery is performed more than 30 days after discharge from the primary admission.

 

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Epidemiology of Acute Mesenteric Ischemia

 

 

Authors - Karri Kase, Annika Reintam Blaser, Kadri Tamme, Merli Mändul, Alastair Forbes, Peep Talving & Marko Murruste

A visual abstract for this article has been requested.  Unknown when it will be completed.

 

 

Abstract

Background

There is a lack of population-based studies on acute mesenteric ischemia (AMI). We have therefore performed a nationwide epidemiological study in Estonia, addressing incidence, demographics, interventions and mortality of AMI.

 

Methods

A retrospective population-based review was conducted of all adult cases of AMI accrued from the digital Estonian Health Insurance Fund and Causes of Death Registry for 2016–2020 based on international classification of diseases (ICD-10) diagnostic codes and procedure codes (NOMESCO).

 

Results

Overall, 577 cases of AMI were identified—an annual incidence of 8.7 per 100,000. The median age was 79 (range 32–104) and 57% were female. Predominating comorbidities included hypertensive disease (81%), atherosclerosis (67%), and atrial fibrillation (52%). The majority of cases (60%) were caused by superior mesenteric artery occlusion (thrombosis 54%, embolism 12%, and unclear 34%). Inferior mesenteric artery occlusion occurred in 7%, non-occlusive mesenteric ischemia in 7%, venous thrombosis in 4%, whereas the type remained unclear in 21% of cases. 40% of patients received intervention (revascularization and/or intestinal resection) and 13% active non-operative treatment. In 21% an exploratory laparotomy or laparoscopy revealed unsalvageable bowel prompting end-of-life care, which was the only management in a further 25% of cases.

 

Conclusions

The population-based annual incidence of AMI in Estonia was 8.7 per 100,000 during the study period. The overall hospital mortality and 1 year mortality were 64% and 74%, respectively. In the 53% of patients who received active treatment hospital mortality was 32% and 1 year all-cause mortality was 51%.

 

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Nipple Sparing Mastectomy Technique to Reduce Ischemic Complications: Preserving Important Blood Flow Based on Breast MRI

 

 

Authors - Mardi R. Karin, Sunita Pal, Debra Ikeda, Max Silverstein & Arash Momeni

 

Abstract

Background

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed. However, nipple areolar complex (NAC) and mastectomy skin necrosis represent significant complications requiring reoperation and revision. Breast MRI, often obtained for oncologic assessment, can visualize the dominant breast and NAC vascular supply. This study describes the surgical technique utilizing breast MRI blood flow information to preserve important NAC blood supply, thereby, reducing ischemic complications.

 

Methods

After IRB approval, a prospectively maintained database of all NSM by a single breast surgeon from 2018 to 2020 formed the study group. Preoperative contrast enhanced Breast MRI analysis determined the dominant NAC blood supply. Intraoperatively, the dominant Internal Mammary Artery Perforator (IMP) to the NAC was preserved (IMP-NSM). The IMP-NSM surgical technique preserving the IMP blood flow, evaluation of breast MRI blood flow patterns, surgical findings, and ischemic complications were analyzed.

 

Results

114 NSM were performed in 74 patients (mean age: 49 years [range, 22–73 years], BMI 25.8 kg/m2 [range, 19–41 kg/m2]). Breast MRI identified the dominant IMP to the NAC in 92%. IMP preservation was successful in 89% (101/114). Necrosis requiring NAC removal occurred in 0.9% (1/114), and skin necrosis reoperation in 1.8% (2/114). Including all post-operative necrosis occurred in 10.5% (12/114), statistically significantly lower compared to the literature for NSM assessing MRI blood flow data without surgical IMP preservation (necrosis 24.4%, p < 0.001) (Bahl et al. in J Am Coll Surg 223(2):279–285, 2016) utilizing Doppler for IMP preservation (necrosis 37%, p < 0.001) (Swistel et al. in Plast Reconstr Surg Glob Open 2(8):e198, 2014) and dividing the IMP in all (necrosis 31.4%, p < 0.001) (Ahn et al. in Eur J Surg Oncol 44(8):1170–1176, 2018).

 

Conclusions

The IMP-NSM surgical technique preserves the dominant blood supply to the NAC, thereby, decreasing ischemic complications.

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Comparing Effects of Bariatric Surgery on Body Composition Changes in Metabolically Healthy and Metabolically Unhealthy Severely Obese Patients

 

 

Authors - Minoo Heidari Almasi, Maryam Barzin, Maryam Mahdavi, Alireza Khalaj, Danial Ebrahimi, Majid Valizadeh & Farhad Hosseinpanah

 

Abstract

Background

Among two popular obesity phenotypes, metabolically healthy severely obese (MHSO) and metabolically unhealthy severely obese (MUSO), it is important to clarify whether or not those with MHSO phenotype would benefit from bariatric surgery in terms of an improvement in body composition parameters.

 

Methods

A prospective cohort was conducted on a total of 4028 participants (1404 MHSO and 2624 MUSO) who underwent bariatric surgery; MHSO was defined as having abnormalities in none or one of these four parameters: systolic blood pressure and/or diastolic blood pressure, triglycerides, fasting plasma glucose, and high-density lipoprotein. Otherwise, the definition of MUSO was met. Body composition analysis was performed at the baseline and 6-, 12-, 24-, and 36-month post-surgery using bioelectrical impedance analyzer.

 

Results

Both phenotypes showed a significant decrease in fat mass (FM) and fat-free mass (FFM) and a significant increase in EWL% and TWL% (Ptrend < 0.05). FFM, FM%, and excess weight loss (EWL%) were significantly different between the two phenotypes (Pbetween < 0.05) during the follow-up. Multivariate linear regression demonstrated that compared to MUSO patients, MHSO individuals experienced a greater increase in total weight loss (TWL%) and EWL% at 12- and 24-month and in EWL% at 36-month post-surgery and also a lower decrease in the FFML/WL% after 12 months.

 

Conclusion

Despite a lower decrease of FFML/WL% and a greater increase in TWL and EWL in MHSO phenotype at some time points, there were no clinically significant differences between the study groups in terms of body composition changes throughout the follow-up period.

 

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The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis

 

 

Authors - Sneha Rajiv Jain, Vasundhara Lakshmi Kandarpa, Clyve Yu Leon Yaow, Winson JianHong Tan, Leonard Ming Li Ho, Sharmini Su Sivarajah, Jia Lin Ng, Cheryl Xi Zi Chong, Darius Kang Lie Aw, Fung Joon Foo & Frederick Hong Xiang Koh

 

Abstract

Background

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery.

 

Methods

Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien–Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity.

 

Results

Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781–0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674–53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI − 2.707–63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI − 6.77–55.900, p = 0.104) postoperatively.

 

Conclusions

As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

 

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Delayed Gastric Emptying and Gastric Remnant Function After Pancreaticoduodenectomy: A Systematic Review of Objective Assessment Modalities

Authors - Tim H.-H. Wang, Anthony Y. Lin, Keno Mentor, Gregory O’Grady & Sanjay Pandanaboyana

 

Abstract

Background

Delayed gastric emptying (DGE) is a frequent complication after pancreaticoduodenectomy (PD). The diagnosis of DGE is based on International Study Group for Pancreatic Surgery (ISGPS) clinical criteria and objective assessments of DGE are infrequently used. The present literature review aimed to identify objective measures of DGE following PD and determine whether these measures correlate with the clinical definition of DGE.

 

Methods

A systematic search was performed using the MEDLINE Ovid, EMBASE, Google Scholar and CINAHL databases for studies including pancreatic surgery, delayed gastric emptying and gastric motility until June 2022. The primary outcome was modalities undertaken for the objective measurement of DGE following PD and correlation between objective measurements and clinical diagnosis of DGE. Relevant risk of bias analysis was performed.

 

Results

The search revealed 4881 records, of which 46 studies were included in the final analysis. There were four objective modalities of DGE assessment including gastric scintigraphy (n = 28), acetaminophen/paracetamol absorption test (n = 10), fluoroscopy (n = 6) and the 13C-acetate breath test (n = 3). Protocols were inconsistent, and reported correlations between clinical and objective measures of DGE were variable; however, amongst these measures, at least one study directly or indirectly inferred a correlation, with the greatest evidence accumulated for gastric scintigraphy.

 

Conclusion

Several objective modalities to assess DGE following PD have been identified and evaluated, however are infrequently used. Substantial variability exists in the literature regarding indications and interpretation of these tests, and there is a need for a real-time objective modality which correlates with ISGPS DGE definition after PD.

 

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