Featured Articles in Jul 2022

Evaluation and Treatment of Esophageal Achalasia

 

Author list:   

Marco G. Patti & Fernando A. M. Herbella

 

No Abstract

 

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Inspirational Women in Surgery: Dr. Olive Kobusingye, Uganda

 

Author list:   

Charles Mock

No abstract

 

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Understanding Societal Preferences Can Inform the Discussion Seeking to Promote Gender Equity in Surgery

Author list:   Savio George Barreto

Abstract: NA
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We Asked the Experts: When is a Laparoscopic Fundoplication warranted for GERD

 

 

Author list:  

Sarah K. Thompson & David I. Watson

 

No Abstract

 

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Nationwide Study on Stress Perception Among Surgical Residents

 

Author list: 

Laura C. Guglielmetti, Christian Gingert, Anna Holtz, Reinhard Westkämper, Jochen Lange & Michel Adamina

 

Abstract

Objective

Declining number of applicants and high attrition of residents are a dire reality. Surgeons in training are confronted to various stressors which interfere with their performance and may promote burnout. This study measures stress levels of Swiss surgical residents.

 

Methods

Swiss surgery residents taking the Surgical Basic Exam from 2016 to 2020 completed the Perceived Stress Scale 10 (PSS). The PSS measures how unpredictable, uncontrollable, and overloaded the respondents evaluate their work life. Scores up to 13 are normal, and scores around 20 are highly pathologic. High subscores of helplessness (PH) and lower subscores of self-efficacy (PSE) indicate distress.

 

Results

A total of 1694 questionnaires were evaluated (return rate 95.7%). Resident median (m) age was 29 years, 43.5% were female, and 72.7% of the residents were in their first 2 years of training. Residents reported a high PSS (m = 15), a high PH (m = 9), and an ordinary PSE (m = 5). Females reported worse PSS (p < 0.001), PH (p < 0.001), and PSE (p = 0.036). In multivariable analysis, male sex (p < 0.001), aiming at orthopedic (p = 0.017) or visceral surgery (p = 0.004), and French as mother tongue (p = 0.037) predicted lower stress levels, while graduating from a country not adjacent to Switzerland led to higher stress (p = 0.047).

 

Conclusion

Perceived stress levels are high in this prospective and representative cohort study of Swiss surgical residents. Females endured significantly worse stress and helplessness levels than males. These figures are worrisome as they may directly contribute to the declining attractivity of surgical residencies. Detailed sex-specific analysis and correction of stressors are urgently needed to improve residency programs.

 

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Ukraine War: A Case of Surgical Treatment of a Gunshot Wound to the Left Scapular Region

 

 

Author list: 

Volodymyr M. Rogovskyi, Rostislav V. Gybalo, Igor A. Lurin, Yuriy Y. Sivash, Denys V. Oklei & Igor A. Taraban

 

 

Abstract

Introduction

The incidence of vascular damage in modern combat conflicts is 5 times higher than in previous military conflicts, with one in five wounded having uncontrolled severe blood loss. Treatment of gunshot wounds of the main arteries is a complex multi-level process, which can be done only in the case of close cooperation of related surgical specialties.

 

Case report

This case report details treatment of a 40-year-old man who was admitted with a gunshot wound to the left shoulder with injury of the distal axillary and proximal brachial arteries. Primary surgical treatment consisted of venous interposition graft of the injured artery and debridement of the scapular wounds in a peripheral hospital. He was transferred to Main Military Medical Clinical Center in Kyiv with acute thrombosis of the vascular repair graft. Urgent reoperation was performed, with removal of the previously placed vascular graft and revascularization of the distal axillary and proximal brachial artery with reverse venous graft, with accompanying fasciotomy.

 

Conclusion

This case demonstrates the crucial role of rapid evacuation of wounded to a specialized level of care for complex cases such as arterial reconstruction.

 

Introduction

Clinical and epidemiological studies of injuries during NATO campaigns in Iraq and Afghanistan showed that the frequency of vascular damage was 12% and this significantly exceeded the rate of vascular damage in World War II and the wars in Korea and Vietnam (1–3%) [1, 2]. The incidence of vascular damage in modern combat conflicts is 5 times higher than in previous military conflicts, with one in five wounded having uncontrolled severe blood loss. The frequency of damage to the vessels of the extremities was 70–80%, vessels of the neck—10–15%, and vessels of the trunk—5–10% [3].

 

Such injuries are often characterized by the serious condition of the victim, the variability of the clinical course, the unpredictability of the wound canal, and the need for urgent surgery [4]. The severity of a gunshot wound, its consequences, complications, surgical tactics, and treatment outcome depend on the ballistic, anatomical, and morphological characteristics of the wound [5, 6].

 

Vascular ligation was a major surgical strategy during World War I with the hope of collateralization; however, ligation often led to progression to irreversible ischemia and subsequent limb amputation. Previous attempts at revascularization using venous grafting were very rarely performed during World War II. The use of specially designed vascular instruments and venous autografts by American surgeons became a necessity in military surgical practice during the Vietnam War. The Vietnam Vascular Registry has documented potential complications in trying to treat vascular damage. Of the 950 revascularizations performed with autologous vein, one-third of patients developed complications, of which 64% were thrombosis. This resulted in a high frequency of amputations (27.1–31.5%), significant disability in those wounded (45.0%), and fatalities in 12.0% of cases [1, 6, 7].

 

Treatment of gunshot wounds of the main arteries is a complex multi-level process, which can be done only in the case of close cooperation of related surgical specialties. First of all, it is traumatology, along with reconstructive and plastic surgery, anesthesiology, and intensive care [8]. The ability to conduct open and endovascular treatment remains the most important direction in providing assistance to the wounded in hostilities [2].

 

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Surgeon Bias in Postoperative Opioid Prescribing

 

Author list: 

Shruti Zaveri, Tamar B. Nobel, Prerna Khetan, Maya Srinivasan & Celia M. Divino

 

 

Abstract

Background

The misuse of opioids is a serious national crisis that is fueled by prescriptions medications. Opioid prescribing habits are known to be highly varied amongst providers. The purpose of this study is to identify patient and surgeon characteristics that predict postoperative opioid prescribing patterns.

 

Methods

This is a serial cross-sectional analysis of 20,497 patients who underwent general surgical procedures at a large academic center. Our primary outcome was the total amount of opioids prescribed within 30 days of the surgery. Univariate and multivariate linear regression models were used to identify patient and provider characteristics that were associated with increased opioids prescribed.

 

Results

Among patient characteristics studied, patient age, sex, ethnicity, and insurance status were found to have a significant association with the amount of opioids prescribed. Younger patients and male patients received higher morphine milligram equivalents (MMEs) on discharge (p < 0.05). Patients of Hispanic background were prescribed significantly lower opioids compared to Non-Hispanic patients (p < 0.0001). Among the provider characteristics studied, surgeon sex and years in practice were significantly predictive of the amount of opioids prescribed, with surgeons in practice for <15 years prescribing the highest MMEs (p < 0.0001).

 

Conclusion

While opioid prescribing habits after surgery seem highly varied and arbitrary, we have identified key predictors that highlight biases in surgeon opioid prescribing patterns. Surgeons tend to prescribe significantly larger amounts of opioids to younger, male patients and those of certain ethnic backgrounds, and surgeons with fewer years in practice are more likely to prescribe more opioids.

 

 

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Safety and Efficacy of Single-Session Radiofrequency Ablation Treatment for Benign Non-toxic Multinodular Goiter

 

 

Author list: 

Brian Hung Hin Lang & Matrix Man Him Fung

 

 

Abstract

Background

Radiofrequency ablation (RFA) is an effective treatment for benign thyroid nodules. However, it remains unclear if ablating multiple nodules in single-session offers comparable safety and efficacy to ablating single nodule. Our study compared early complication rate and 6-month nodule shrinkage between multiple-nodules ablation and single-nodule ablation by RFA.

 

Methods

Among the 174 eligible patients undergoing RFA of one or more benign thyroid nodules, 85 (48.8%) had single-nodule ablation (group I) while 89 (51.1%) had two or three nodules ablation (group II). The 6-month nodule shrinkage of each nodule (by volume reduction ratio) (VRR) was calculated by (Baseline volume − volume at 6-month)/(Baseline volume)*100 and compared between two groups. To determine independent predictors for VRR, a multivariate analysis was done by logistic regression analysis.

 

Results

Patients in group II reported significantly higher pain scores during and 2-h after treatment than group I (42.31 vs. 29.66, p = 0.029 and 38.21 vs. 26.18, p = 0.037, respectively). Two vocal cord paresis occurred in each group. 3- and 6-month VRR of the largest nodule were comparable between two groups (67.39% vs. 63.89%, p = 0.248 and 77.29% vs. 73.38%, p = 0.182). Similar 3- and 6-month VRR were observed for 2 and 3 largest nodules in group II. In multivariate analysis, total energy given per nodule volume (OR = 1.007, 95% CI = 1.001–1.012, p = 0.036) was the only independent predictor for 6-month VRR.

 

Conclusion

In the presence of multinodular goiter, ablating two or more nodules by RFA within one session appears to offer a comparable level of safety and efficacy to ablating single nodule.

 

 

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Sleeve Gastrectomy and Cholecystectomy are Safe in Obese Patients with Asymptomatic Cholelithiasis

Author list: 

Tamer A. A. M. Habeeb, Mohammad Kermansaravi, Mariano Eduardo Giménez, Mallikarjuna N. Manangi, Hosam Elghadban, Samar A. Abdelsalam, Abd-Elrahman M. Metwalli, Muhammad Ali Baghdadi, Abdelrahman A. Sarhan, Adel Mahmoud Moursi & Ahmed K. El-Taher

 

Abstract

Background

Obesity is a severe health problem. Gallstones may symptomatize after sleeve gastrectomy (SG). Concomitant laparoscopic cholecystectomy (LC) with SG is controversial. The effects of SG and LC versus delayed LC following SG in obese patients with asymptomatic gallbladder stones were evaluated.

 

Methods

A randomized trial of 222 morbidly obese patients with gallbladder stones divided them into two equal groups: SG + LC and SG-only. This multicenter study conducted from January 2016 to January 2019.

 

Results

Except for operative time and postoperative hospital stay, there was no statistically significant difference between LSG + LC group and SG group (P < 0.001). In SG + LC group, LC added 40.7 min to SG, three patients (3%) required conversion, early postoperative complications occurred in 9 cases (9/111, 9%), three cases required re-intervention (3%). In SG group, the complicated cases required LC were 61 cases (61/111, 55%). Acute cholecystitis (26/61, 42.7%) was the most common gallstone symptoms. Most complicated cases occurred in the first-year follow-up (52/61, 85%). In the delayed LC group (61 patients), operative time was 50.13 ± 1.99 min, open conversion occurred in 2 cases (2/61, 3.2%), early postoperative complications occurred in four patients (4/61, 6.4%) and postoperative re-intervention were due to bile leaks and cystic artery bleeding (2/61, 3.2%).

 

Conclusions

SG with LC prolongs the operative time and hospital stay, but the perioperative complications are the same as delayed LC; LC with SG minimizes the need for a second surgery. Concomitant LC with SG is safe.

 

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Elevated Serum Triglyceride Levels in Acute Pancreatitis: A Parameter to be Measured and Considered Early

Author list: 

Nils Jimmy Hidalgo, Elizabeth Pando, Piero Alberti, Laura Vidal, Rodrigo Mata, Nair Fernandez, Maria Jose Gomez-Jurado, Cristina Dopazo, Laia Blanco, Stephanie Tasayco, Xavier Molero, Joaquim Balsells & Ramon Charco

 

Abstract

Background

The value of serum triglycerides (TGs) related to complications and the severity of acute pancreatitis (AP) has not been clearly defined. Our study aimed to analyze the association of elevated levels of TG with complications and the severity of AP.

 

Methods

The demographic and clinical data of patients with AP were prospectively analyzed. TG levels were measured in the first 24 h of admission. Patients were divided into two groups: one with TG values of<200 mg/dL and another with TG≥200 mg/dL. Data on the outcomes of AP were collected.

 

Results

From January 2016 to December 2019, 247 cases were included: 200 with TG<200 mg/dL and 47 with TG≥200 mg/dL. Triglyceride levels≥200 mg/dL were associated with respiratory failure (21.3 vs. 10%, p=0.033), renal failure (23.4 vs. 12%, p=0.044), cardiovascular failure (19.1 vs. 7.5%, p=0.025), organ failure (34 vs. 18.5%, p=0.02), persistent organ failure (27.7 vs. 9.5%, p=0.001), multiple organ failure (19.1 vs. 8%, p=0.031), moderately severe and severe AP (68.1 vs. 40.5%, p=0.001), pancreatic necrosis (63.8 vs. 34%, p<0.001), and admission to the intensive care unit (27.7 vs. 9.5%, p=0.003). In the multivariable analysis, a TG level of≥200 mg/dL was independently associated with respiratory, renal, and cardiovascular failure, organ failure, persistent organ failure, multiple organ failure, pancreatic necrosis, severe pancreatitis, and admission to the intensive care unit (p<0.05).

 

Conclusions

In our cohort, TG≥200 mg/dL was related to local and systemic complications. Early determinations of TG levels in AP could help identify patients at risk of complications.

 

 

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Systematic Reviews and Meta-Analyses: Bullying, Discrimination, Harassment, Sexual Harassment, and the Fear of Retaliation During Surgical Residency Training: A Systematic Review

 

Author list:

Arianna L. Gianakos, Julie A. Freischlag, Angela M. Mercurio, R. Sterling Haring, Dawn M. LaPorte, Mary K. Mulcahey, Lisa K. Cannada & John G. Kennedy

 

Abstract

Background

The negative effects of bullying, discrimination, harassment, and sexual harassment (BDHS) on well-being and productivity of surgical residents in training have been well documented. Despite this, little has changed over the past decade and these behaviors continue. The purpose of this study was to determine the prevalence of each abusive behavior experienced by residents, identify the perpetrators, and examine the reporting tendency.

 

Methods

A systematic review of articles published between 2010 and 2020 in the MEDLINE, EMBASE, and Cochrane databases was performed following PRISMA guidelines. The following search terms were used: bullying, harassment, sexual harassment, discrimination, abuse, residency, surgery, orthopedic surgery, general surgery, otolaryngology, obstetrics, gynecology, urology, plastic surgery, and training.

 

Results

Twenty-five studies with 29,980 surgical residents were included. Sixty-three percent, 43, 29, and 27% of surgical residents experienced BDHS, respectively. Female residents reported experiencing all BDHS behaviors more often. Thirty-seven percent of resident respondents reported burnout, and 33% reported anxiety/depression. Attending surgeons, followed by senior co-residents, were the most common perpetrators. Seventy-one percent did not report the behavior to their institution. Fifty-one percent stated this was due to fear of retaliation. Of those who reported their experiences, 56% stated they had a negative experience reporting.

 

Conclusion

Our review demonstrates high prevalence rates of BDHS experienced by residents during surgical training, which have been associated with burnout, anxiety, and depression. The majority of residents did not report BDHS due to fear of retaliation. Residency programs need to devise methods to have a platform for residents to safely voice their complaints.

 

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Volatile Organic Compounds in the Early Diagnosis of Non-healing Surgical Wounds: A Systematic Review

Author list:

Nicola Reeves, Samuel Phillips, Aron Hughes, Sarah Maddocks, Matthew Bates, Jared Torkington, Lori Robins & Julie Cornish

 

Abstract

Background

The normal healing of surgical wounds can be disrupted by infection and/or dehiscence, leading to development of chronic, non-healing wounds (NHW). Diagnosis of NHWs is via clinical acumen and analysis of microbiology wound swabs. Volatile organic compounds (VOCs) are emitted generally by human subjects and specifically as products of bacterial metabolism and are detected in the wound area. This systematic review will assess the potential use of VOCs released by surgical wounds as a non-invasive method for identifying bacterial species and the progression to NHW.

 

Method

A systematic search of studies, via PRISMA guidelines, was conducted. Of 220 papers screened, seven studies were included. Outcome data were extracted on methods for VOC analysis and wound/bacterial VOC profiles.

 

Results

The studies have shown that VOC profiles are identified by two methods: gas chromatography–mass spectrometry and electronic nose. There are VOC profiles associated with causative bacterial species, with early indications that they could be anatomically specific or could monitor treatment effects.

 

Conclusion

VOC profiling of bacterial species within wounds is possible and could become a point of care test. More research is needed on specific VOC profiles to wound location and whether these profiles may predict progression to NHW.

 

 

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