Featured Articles in Jul 2021

How Much is Enough? Public Perception of Minimum Surgeon Volumes

 

 

Author list: Julia M. Danford, Sandra L. Wong, Brenda Sirovich, Daniel Underbaake & Meredith J. Sorensen

 

Abstract:

Background

A large body of literature supports an association between surgical volumes and outcomes. Research on this subject has resulted in attempts to quantify minimum volume standards for specific surgeries. However, the extent to which the public takes interest in or is able to interpret surgical volume information is not known.

Methods

We designed a 38-question online survey to assess respondents’ knowledge and beliefs about minimum surgical volume standards, and other factors influencing choice of surgeon. Participants, recruited through Amazon Mechanical Turk, an online crowdsourcing marketplace, were specifically asked to estimate minimum volume standards for four different operations (hernia repair, knee replacement, mitral valve repair, and Whipple) and to assess the implications of specific surgeon volumes for decision-making in two hypothetical scenarios.

Results

Among 2024 participants, 81% attested that surgeons should be subject to minimum volume standards. A small minority (19%) reported having prior knowledge of a link between surgeon volumes and outcomes. Respondents’ mean estimates for appropriate minimum annual volumes across four operations were directly correlated with surgical complexity (5 for inguinal hernia repair, 25 for Whipple), while published minimum standards fall with increasing surgical complexity (25 for hernia repair, 5 for Whipple). These findings were validated by participants’ stated intentions: 55% would proceed with a hernia repair by a surgeon with annual volume of 25, while 13% would proceed with a Whipple when annual volume was 5.

Conclusion

The concept of minimum surgical volumes is intuitively important to the lay public. However, the general public’s skewed expectations of minimum volume standards demonstrate an inability to interpret surgical volume numbers meaningfully in clinical settings without appropriate context.


URL:   www.dx.doi.org/10.1007/s00268-021-06015-5

 


APatients over 65 years with Acute Complicated Calculous Biliary Disease are Treated Differently

Author list: Gary A. Bass, Amy E. Gillis, Yang Cao & Shahin Mohseni for the European Society for Trauma and Emergency Surgery (ESTES) Cohort Studies Group

 

Abstract:

Methods

The European Society of Trauma and Emergency Surgery (ESTES) undertook a snapshot audit of patients undergoing emergency hospital admission for ACCBD between October 1 and 31 2018, comparing patients under and ≥ 65 years. Mortality, postoperative complications, time to operative intervention, post-acute disposition, and length of hospital stay (LOS) were compared between groups. Within the ≥ 65 cohort, comorbidity burden, mortality, LOS, and disposition outcomes were further compared between patients undergoing operative and non-operative management.

 

Results

The median age of the 338 admitted patients was 67 years; 185 patients (54.7%) of these were the age of 65 or over. Significantly fewer patients ≥ 65 underwent surgical treatment (37.8% vs. 64.7%, p < 0.001). Surgical complications were more frequent in the ≥ 65 cohort than younger patients, and the mean postoperative LOS was significantly longer. Postoperative mortality was seen in 2.2% of patients ≥ 65 (vs. 0.7%, p = 0.253). However, operated elderly patients did not differ from non-operated in terms of comorbidity burden, mortality, LOS, or post-discharge rehabilitation need.

 

Conclusions

Few elderly patients receive surgical treatment for ACCBD. Expectedly, postoperative morbidity, LOS, and the requirement for post-discharge rehabilitation are higher in the elderly than younger patients but do not differ from elderly patients managed non-operatively. With multidisciplinary perioperative optimization, elderly patients may be safely offered optimal treatment.


URL: www.dx.doi.org/10.1007/s00268-021-06052-0


Patient-Reported Quality of Life Following Laparotomy in a Resource-Limited Setting

 

 

Author list: Laura N. Purcell, Rachel Reiss, Mercy Mtalimanja, Patricia Kuyenda, Vanessa Msosa, Katherine D. Westmoreland & Anthony Charles

 

 

Abstract:

Introduction

The burden of surgical diseases is high in sub-Saharan Africa. Despite limitations to surgical care access, health-related quality of life (HRQoL) data following surgical intervention are scarce.

 

Methods

We performed a 3-month prospective observational study of adult patients undergoing an abdominal operation. We administered the Patient-Reported Outcome Measurement Information System (PROMIS)-25 and Index of Independence in Activities of Daily Living questionnaire preoperatively (to postoperative day [POD] #1), POD#7, and POD#30. PROMIS-25 HRQoL domains were measured and converted to standardized T-scores (median 50, minimal important clinical difference 3).

 

Results

Of the 117 laparotomy patients who were enrolled, 89 (76.1%) were male with a median age of 39 years (IQR 27–54). Operations were primarily for intestinal volvulus (n = 30, 28.3%) and intestinal perforation (n = 29, 27.4%). We completed a total of 80 (68.4%), 95 (81.2%), and 77 (65.8%) surveys preoperatively, at POD#7, and POD#30, respectively. Preoperatively patients showed high median levels of anxiety (56), depression (60), fatigue (63), and pain interference (62), which all improved postoperatively. Mobility was poor preoperatively (31) and showed improvement during recovery but remained poor [POD#7: 32, POD#30: 39]. Pain intensity was high (10/10) preoperatively and improved to 3/10 by POD#30. Patients with complications compared to those without had clinically significant worse HRQoL in all domains measured by POD#30.

Discussion

Abdominal surgery patients in a resource-limited setting present with poor HRQoL, which improves postoperatively. Mobility remained poor throughout follow-up despite improved pain scores. Our findings highlight the need for improved HRQoL and pain control among surgical patients.


URL:  www.dx.doi.org/10.1007/s00268-021-06050-2

 


Development of a Rapid Intraoperative Point-of-Care Method Using Tissue Suspension to Differentiate Parathyroid Tissue

 

Author list: Toyone Kikumori, Masahiro Shibata & Dai Takeuchi

 

 

Abstract:

Background

We reported that aspartate aminotransferase (AST)/lactate dehydrogenase (LDH) ratio of a tissue suspension can precisely differentiate normal and hyperfunctioning parathyroid tissue (PT) from other tissues. However, in these studies, LDH and AST were measured using the standard method for blood samples, with a turnaround time of approximately 1 h, hampering clinical application. Here, we developed a rapid and robust method to differentiate PT instead of using frozen sections.

Methods

Excised specimens from 28 patients (n = 69) who underwent thyroid or parathyroid surgery between October 2019 and April 2020 were analyzed. AST and LDH were measured in suspensions of PT or other tissues, using both the standard method in the in-facility laboratory and a point-of-care testing device (NX500, Fujifilm, Japan).

Results and conclusions

A good correlation was found between the standard method and NX500 for AST and LDH levels >10 IU/L. In the analyses using 52 specimens with ≥ 10 IU/L of both AST and LDH measured using the NX500, PT was distinguished with 100% sensitivity and specificity using an optimal cutoff AST/LDH ratio of 0.48. The turnaround time was estimated to be less than 10 min. This method could be a cost- and labor-effective alternative to frozen sections to reduce the incidence of postoperative hypoparathyroidism and improve the outcome of primary hyperparathyroidism in low-resource areas.

 


URL: www.dx.doi.org/10.1007/s00268-021-06067-7

 

 


Recurrence of Non-functional Pancreatic Neuroendocrine Tumors After Curative Resection

 

 

Author list: Ding-Hui Dong, Xu-Feng Zhang, Alexandra G. Lopez-Aguiar, George Poultsides, Flavio Rocha, Sharon Weber, Ryan Fields, Kamran Idrees, Cliff Cho, Shishir K. Maithel & Timothy M. Pawlik

 

Abstract:

Background

Patients can experience recurrence following curative-intent resection of non-functional pancreatic neuroendocrine tumors (NF-pNETs). We sought to develop a nomogram to risk stratify patients relative to recurrence following resection of NF-pNETs.

 

Methods

Patients who underwent curative-intent resection for NF-pNETs between 1997 and 2016 were identified from a multi-institutional database. The impact of clinicopathologic factors, including tumor burden score (TBS) (TBS2 = (maximum tumor diameter)2 + (number of tumors)2), was assessed relative to recurrence-free survival (RFS), and a nomogram was developed and internally validated.

 

Results

With a median follow-up of 31.0 months (IQR 11.3–56.6 months), 66 (15.8%) out of 416 patients in the cohort experienced tumor recurrence. Overall, 3-, 5-, and 10-year RFS following curative-intent resection was 83.2%, 74.0%, and 44.7%, respectively. Several factors were associated with risk of recurrence including tumor grade (referent G1: G2, HR 4.07, 95% CI 2.29–7.26, p < 0.001; G3, HR 10.83, 95% CI 3.72–31.53, p < 0.001), lymph node metastasis (LNM) (HR 4.71, 95% CI 2.69–8.26, p < 0.001), as well as TBS (referent low: medium, HR 4.36, 95% CI 2.06–9.24, p < 0.001; high, HR 6.04, 95% CI 2.96–12.31, p < 0.001). A weighted nomogram including tumor grade (G1 0, G2 54.19, G3 100), LNM (N0 0, N1 42.06), and TBS (low 0, medium 44.07, high 56.48) was developed. The discriminatory power of the nomogram was very good with a C-index of 0.75 (95% CI, 0.66–0.79) in the training cohort and 0.71 (95% CI, 0.65–0.75) in the validation cohort. In addition, the nomogram performed better than the current 8th edition of AJCC TNM staging system, which had a C-index of 0.67 (95% CI, 0.60–0.73).

 

Conclusions

A nomogram that incorporated tumor grade, LNM, and TBS was established that had good discrimination and calibration. The nomogram may be an effective tool to stratify patients relative to recurrence risk following resection of NF-pNETs.


URL: www.dx.doi.org/10.1007/s00268-021-06020-8

 


My First Paper The Clinical Significance of Lymph Node Ratio and Ki-67 Expression in Papillary Thyroid Cancer

 

Author list:  Helene Lindfors, Catharina Ihre Lundgren, Jan Zedenius, C. Christofer Juhlin & Ivan Shabo

 

 

Abstract:

Background

The N stage in papillary thyroid cancer (PTC) is an important prognostic factor based on anatomical localization of cervical lymph nodes (LNs) only and not the extent of lymphatic metastasis. In this retrospective study, the clinical significance of lymph node ratio (LNR) and tumor cell proliferation in relation to the conventional classification of PTC was explored.

Methods

Patients diagnosed with PTC at the Karolinska University Hospital in Stockholm, Sweden, during the years 2009–2011 were included. The LNR, defined as the number of metastatic LNs divided by the total number of LNs investigated, and the Ki-67 index were analyzed in relation to clinical data.

Results

The median number of LN removed was 16 with the following N stage distribution: N0 (26%), N1a (45%), and N1b (29%). A Ki-67 index of ≥3% was significantly correlated with the presence of metastases and tumor recurrence with a sensitivity of 50% and specificity of 80% (p = 0.015). Lymph node ratio ≥21% was related to tumor recurrence with sensitivity of 89% and specificity of 70% (p = 0.006). Patients with LN metastases in the lateral cervical compartment only had significantly lower LNR (14.5%) compared to those with both central and lateral cervical metastases (39.5%) (p = 0.004) and exhibited no tumor recurrence. Increased Ki-67 index was significantly related to LNR ≥21% (p = 0.023) but was not associated with N stage.

Conclusions

The Ki-67 proliferation index and LNR may better reflect the malignant behavior of PTC compared to the anatomical classification of LN metastases solely.


URL: www.dx.doi.org/10.1007/s00268-021-06070-y

 

 


We Asked the Experts Autotransfusion for the Provision of Blood in Lower-and-Middle-Income Countries

 

 

Author list: Timothy Craig Hardcastle

 

Abstract:  No Abstract


URL:  www.dx.doi.org/10.1007/s00268-021-06089-1

 


Systematic Reviews and Meta-Analyses Conflicting Guidelines: A Systematic Review on the Proper Interval for Colorectal Cancer Treatment

Author list: Charlotte J. L. Molenaar, Loes Janssen, Donald L. van der Peet, Desmond C. Winter, Rudi M. H. Roumen & Gerrit D. Slooter

 

Abstract:

Background

Timely treatment for colorectal cancer (CRC) is a quality indicator in oncological care. However, patients with CRC might benefit more from preoperative optimization rather than rapid treatment initiation. The objectives of this study are (1) to determine the definition of the CRC treatment interval, (2) to study international recommendations regarding this interval and (3) to study whether length of the interval is associated with outcome.

 

Methods

We performed a systematic search of the literature in June 2020 through MEDLINE, EMBASE and Cochrane databases, complemented with a web search and a survey among colorectal surgeons worldwide. Full-text papers including subjects with CRC and a description of the treatment interval were included.

 

Results

Definition of the treatment interval varies widely in published studies, especially due to different starting points of the interval. Date of diagnosis is often used as start of the interval, determined with date of pathological confirmation. The end of the interval is rather consistently determined with date of initiation of any primary treatment. Recommendations on the timeline of the treatment interval range between and within countries from two weeks between decision to treat and surgery, to treatment within seven weeks after pathological diagnosis. Finally, there is no decisive evidence that a longer treatment interval is associated with worse outcome.

 

Conclusions

The interval from diagnosis to treatment for CRC treatment could be used for prehabilitation to benefit patient recovery. It may be that this strategy is more beneficial than urgently proceeding with treatment.

 


URL:  www.dx.doi.org/10.1007/s00268-021-06075-7


Are Surgeons Working Smarter or Harder? A Systematic Review Comparing the Physical and Mental Demands of Robotic and Laparoscopic or Open Surgery

Author list:  Laura Seohyun Park, Feiyang Pan, Daniel Steffens, Jane Young & Jonathan Hong

 

Abstract:

Background

Minimally invasive surgical techniques such as robotic surgical platforms have provided favourable outcomes for patients, but the impact on surgeons is not well described. This systematic review aims to synthesize and evaluate the physical and mental impact of robotic surgery on surgeons compared to standard laparoscopic or open surgery.

 

Methods

A search strategy was developed to identify peer-reviewed English articles published from inception to end of December 2019 on the following databases: MEDLINE, PubMed, PsycINFO and Embase. The articles were assessed using a modified Newcastle–Ottawa tool.

 

Results

Of the 6563 papers identified, 30 studies were included in the qualitative synthesis of this review. Most of the included studies presented a high risk of bias. A total of 13 and 21 different physical and mental tools, respectively, were used to examine the impact on surgeons. The most common tool used to measure physical and mental demand were surface electromyography (N = 9) and the NASA Task Load Index (NASA-TLX; N = 8), respectively. Majority of studies showed mixed results for physical (N = 10) and mental impact (N = 7). This was followed by eight and six studies favouring RS over other surgical modalities for physical and mental impact, respectively.

 

Conclusion

Most studies showed mixed physical and mental outcomes between the three surgical modalities. There was a high risk of bias and methodological heterogeneity. Future studies need to correlate mental and physical stress with long-term impact on the surgeons.


URL: www.dx.doi.org/10.1007/s00268-021-06055-x


 

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