Featured Articles in July 2019

Surgical Considerations for Pediatric Snake Bites in Low- and Middle-Income Countries

 

 

Article title 

Surgical Considerations for Pediatric Snake Bites in Low- and Middle-Income Countries

 

Author list 

Matthew C. Hernandez, Michael Traynor, John L. Bruce, Wanda Bekker, Grant L. Laing, Johnathon M. Aho, Victor Y. Kong, Denise B. Klinkner, Martin D. Zielinski, Damian L. Clarke

 

Abstract

Background

Snake envenomation is associated with major morbidity especially in low- and middle-income countries and may require fasciotomy. We determined patient factors associated with the need for fasciotomy after venomous snake bites in children located in KwaZulu-Natal, South Africa.

 

Methods

Single institutional review of historical data (2012–2017) for children (<18 years) sustaining snake envenomation was performed. Clinical data, management, and outcomes were abstracted. Syndromes after snake bite were classified according to Blaylock nomenclature: progressive painful swelling (PPS), progressive weakness (PW), or bleeding (B), as it is difficult to reliably identify the species of snake after a bite. Comparative and multivariable analyses to determine factors associated with fasciotomy were performed.

 

Results

There were 72 children; mean age was 7 (±3) years, 59% male. Feet were most commonly affected (n = 27, 38%) followed by legs (n = 18, 25%). Syndromes (according to Blaylock) included PPS (n = 63, 88%), PW (n = 5, 7%), and B (n = 4, 5%). Eighteen patients underwent fasciotomy, and one required above knee amputation. Nine patients received anti-venom. Few patients (15%) received prophylactic beta-lactam antibiotics. Hemoglobin < 11 mg/dL, leukocytosis, INR >1.2, and age-adjusted shock index were associated with fasciotomy. On regression, age-adjusted shock index and hemoglobin concentration < 11 mg/dL, presentation >24 h after snake bite, and INR >1.2 were independently associated with fasciotomy. Model sensitivity was 0.89 and demonstrated good fit.

 

Conclusions

Patient factors were associated with the fasciotomy. These factors, coupled with clinical examination, may identify those who need early operative intervention. Improving time to treatment and the appropriate administration of anti-venom will minimize the need for surgery.

 

Level of evidence

III

 

URL https://rdcu.be/bFAs7

 


Prophylactic Intraperitoneal Onlay Mesh Following Midline Laparotomy—Long-Term Results of a Randomized Controlled Trial

 

 

Author list 

Philippe M. Glauser, Philippe Brosi, Benjamin Speich, Samuel A. Käser, Andres Heigl, Robert Rosenberg, Christoph A. Maurer

 

Abstract

Objectives

Incisional hernia, a serious complication after laparotomy, is associated with high morbidity and costs. This trial examines the value of prophylactic intraperitoneal onlay mesh to reduce the risk of incisional hernia after a median follow-up time of 5.3 years.

 

Methods

We conducted a parallel group, open-label, single center, randomized controlled trial (NCT01003067). After midline incision, the participants were either allocated to abdominal wall closure according to Everett with a PDS-loop running suture reinforced by an intraperitoneal composite mesh strip (Group A) or the same procedure without the additional mesh strip (Group B).

 

Results

A total of 276 patients were randomized (Group A = 131; Group B = 136). Follow-up data after a median of 5.3 years after surgery were available from 183 patients (Group A = 95; Group B = 88). Incisional hernia was diagnosed in 25/95 (26%) patients in Group A and in 46/88 (52%) patients in Group B (risk ratio 0.52; 95% CI 0.36–0.77; p < 0.001). Eighteen patients with asymptomatic incisional hernia went for watchful waiting instead of hernia repair and remained free of symptoms after of a median follow-up of 5.1 years. Between the second- and fifth-year follow-up period, no complication associated with the mesh could be detected.

 

Conclusion

The use of a composite mesh in intraperitoneal onlay position significantly reduces the risk of incisional hernia during a 5-year follow-up period.

 

Trial registration number

Ref. NCT01003067 (clinicaltrials.gov).

 

 


Hypoparathyroidism After Total Thyroidectomy

 

 

Author list 

Guillermo Ponce de León-Ballesteros, David Velázquez-Fernández, F. Javier Hernández-Calderón, Carlos Bonilla-Ramírez, Rafael H. Pérez-Soto, Juan Pablo Pantoja, Mauricio Sierra, Miguel F. Herrera

 

Abstract

Background

Total thyroidectomy is the most common surgical procedure for the treatment of thyroid diseases. Postoperative hypocalcemia/hypoparathyroidism is the most frequent complication after total thyroidectomy. The aim of this study was to evaluate the rate of postoperative hypocalcemia and permanent hypoparathyroidism after total thyroidectomy in order to identify potential risk factors and to evaluate the impact of parathyroid autotransplantation.

 

Patients and Methods

We performed a retrospective analysis of 1018 patients who underwent total thyroidectomy at our institution between 2000 and 2016. Medical records were reviewed to analyze patient features, clinical presentation, management and postoperative complications. Descriptive and inferential statistics were employed based on the natural scaling of each included variable. Statistical significance was set at p ≤ 0.05.

 

Results

Mean ± SD age was 46.79 ± 15.9 years; 112 (11.7%) were males and 844 (88.3%) females. A total of 642 (67.2%) patients underwent surgery for malignant disease. The rate of postoperative hypocalcemia, transient, protracted and permanent hypoparathyroidism was 32.8%, 14.43%, 18.4% and 3.9%, respectively. Permanent hypoparathyroidism was significantly associated with the number of parathyroid glands remaining in situ (4 glands: 2.5%, 3 glands: 3.8%, 1–2 glands: 13.3%; p ˂ 0.0001) [OR for 1–2 glands in situ = 5.32, CI 95% 2.61–10.82]. Other risk factors related to permanent hypoparathyroidism were obesity (OR 3.56, CI 95% 1.79–7.07), concomitant level VI lymph node dissection (OR 3.04, CI 95% 1.46–6.37) and incidental parathyroidectomy without autotransplantation (OR 3.6, CI 95% 1.85–7.02).

 

Conclusions

Identification and in situ preservation of at least three parathyroid glands were associated with a lower rate of postoperative hypocalcemia (30.4%) and permanent postoperative hypoparathyroidism (2.79%).

 

URL https://rdcu.be/bFAtY

 


Trends in the Incidence, Treatment and Outcomes of Patients with Intrahepatic Cholangiocarcinoma in the USA

 

 

Author list 

Lu Wu, Diamantis I. Tsilimigras, Anghela Z. Paredes, Rittal Mehta, J. Madison Hyer, Katiuscha Merath, Kota Sahara, Fabio Bagante, Eliza W. Beal, Feng Shen, Timothy M. Pawlik

 

Abstract

Introduction

Intrahepatic cholangiocarcinoma (ICC) remains an uncommon disease with a rising incidence worldwide. We sought to identify trends in therapeutic approaches and differences in patient outcomes based on facility types.

 

Methods

Between January 1, 2004, and December 31, 2015, a total of 27,120 patients with histologic diagnosis of ICC were identified in the National Cancer Database and were enrolled in this study.

 

Results

The incidence of ICC patients increased from 1194 in 2004 to 3821 in 2015 with an average annual increase of 4.16% (p < 0.001). Median survival of the cohort improved over the last 6 years of the study period (2004–2009: 8.05 months vs. 2010–2015: 9.49 months; p < 0.001). Among surgical patients (n = 5943, 21.9%), the incidence of R0 resection, lymphadenectomy and harvest of ≥6 lymph nodes increased over time (p < 0.001). Positive surgical margins (referent R0: R1, HR 1.49, 95% CI 1.24–1.79, p < 0.001) and treatment at community cancer centers (referent academic centers; HR 1.24, 95% CI 1.04–1.49, p = 0.023) were associated with a worse prognosis. Patients treated at academic centers had higher rates of R0 resection (72.4% vs. 67.7%; p = 0.006) and lymphadenectomy (55.6% vs. 49.5%, p = 0.009) versus community cancer centers. Overall survival was also better at academic versus community cancer programs (median OS: 11 months versus 6 months, respectively; p < 0.001).

 

Conclusions

The incidence of ICC has increased over the last 12 years in the USA with a moderate improvement in survival over time. Treatment at academic cancer centers was associated with higher R0 resection and lymphadenectomy rates, as well as improved OS for patients with ICC.

 

URL https://rdcu.be/bFAue

 


Prehabilitation Before Major Abdominal Surgery

 

 

Author list 

Michael J. Hughes, Rosie J. Hackney, Peter J. Lamb, Stephen J. Wigmore, D. A. Christopher Deans, Richard J. E. Skipworth

 

Abstract

Introduction

Prehabilitation prior to major surgery has increased in popularity over recent years and aims to improve pre-operative conditioning of patients to improve post-operative outcomes. The beneficial effect of such protocols is not well established with conflicting results reported. This review aimed to assess the effect of prehabilitation on post-operative outcome after major abdominal surgery.

 

Methods

EMBASE, Medline, PubMed and the Cochrane database were searched in August 2018 for trials comparing outcomes of patients undergoing prehabilitation involving prescribed respiratory and exercise interventions prior to abdominal surgery. Study characteristics, overall and pulmonary morbidity, length of stay (LOS), maximum inspiratory pressure and change in six-minute walking test (6MWT) distance were obtained. The primary outcome was post-operative overall morbidity within 30 days. Dichotomous data were analysed by fixed or random effects odds ratio. Continuous data were analysed with weighted mean difference.

 

Results

Fifteen RCTs were included in the analysis with 457 prehabilitation patients and 450 control group patients. A significant reduction in overall (OR 0.63 95% CI 0.46–0.87 I2 34%, p = 0.005) and pulmonary morbidity (OR 0.4 95% CI 0.23–0.68, I2 = 0%, p = 0.0007) was observed in the prehabilitation group. No significant difference in LOS (WMD −2.39 95% CI −4.86 to 0.08 I2 = 0%, p = 0.06) or change in 6MWT distance (WMD 9.06 95% CI −35.68, 53.81 I2 = 88%, p = 0.69) was observed.

 

Conclusions

Prehabilitation can reduce overall and pulmonary morbidity following surgery and could be utilised routinely. The precise protocol of prehabilitation has not been completely established. Further work is required to tailor optimal prehabilitation protocols for specific operative procedures.

 

URL https://rdcu.be/bFAur

 


Conventional Versus Minimally Invasive Hartmann Takedown

 

Author list 

Francesco Guerra, Diego Coletta, Celeste Del Basso, Giuseppe Giuliani, Alberto Patriti

 

Abstract

Although end colostomy closure following Hartmann’s procedure is a major surgery that is traditionally performed by conventional celiotomy, over the last decade there has been a growing interest toward the application of different minimally invasive techniques. We aimed at evaluating the relative outcomes of conventional surgery versus minimally invasive surgery by meta-analyzing the available data from the medical literature. The PubMed/MEDLINE, Cochrane Library and EMBASE electronic databases were searched through August 2018. Inclusion criteria considered eligible all comparative studies evaluating open versus minimally invasive procedures. Conventional laparoscopy, robotic and single-port laparoscopy were considered as minimally invasive techniques. Overall morbidity, rate of anastomotic failure, rate of wound complications and mortality were evaluated as primary outcomes. Perioperative details and surgical outcomes were also assessed. The data of a total of 13,740 patients from 26 studies were eventually included in the analysis. There were no significant differences on baseline characteristics such as age, BMI and proportion of high-risk patients between the two groups of patients. As compared to the conventional technique, minimally invasive surgery proved significantly superior in terms of postoperative morbidity, length of hospital stay and rate of incisional hernia. The current literature suggests that minimally invasive surgery should be considered in performing Hartmann’s reversal, if technically viable. However, due to the low level of the available evidence it is impossible to draw definitive conclusions.

 

URL https://rdcu.be/bFAuA

 


Primary Tumor Resection in Patients with Incurable Localized or Metastatic Colorectal Cancer

 

 

Author list 

Constantinos Simillis, Eliana Kalakouti, Thalia Afxentiou, Christos Kontovounisios, Jason J. Smith, David Cunningham, Michel Adamina, Paris P. Tekkis

 

Abstract

Background

To assess the impact of primary tumor resection (PTR) on survival and morbidity in incurable colorectal cancer.

 

Methods

Systematic literature review and meta-analysis to compare PTR versus primary tumor intact (PTI).

 

Results

Seventy-seven studies were included, reporting on 159,991 participants (94,745 PTR; 65,246 PTI). PTR improved overall survival (hazard ratio [HR] 0.59, P < 0.0001; mean difference [MD] 7.27 months, P < 0.0001), cancer-specific survival (HR 0.47, MD 10.80), and progression-free survival (HR 0.76, MD 1.67). Overall survival remained significantly improved during subgroup analysis of asymptomatic patients (HR 0.69, MD 3.86), elderly patients (HR 0.46, MD 7.71), patients diagnosed after 2000 (HR 0.62, MD 7.29), patients with colon (HR 0.58, MD 6.31) or rectal (HR 0.54, MD 6.88) primary tumor, patients undergoing resection of primary tumor versus non-resectional surgery (NRS) to treat primary tumor complications (HR 0.56, MD 8.72), and of studies with propensity score analysis (HR 0.65, MD 5.68). Overall survival per treatment strategy was: [PTI/chemotherapy] 14.30 months, [PTI/bevacizumab] 17.27 months, [PTR/chemotherapy] 21.52 months, [PTR/bevacizumab] 27.52 months. PTR resulted in 4.5% perioperative mortality and 22.4% morbidity (major adverse events 10.2%, minor 18.5%, reoperation 2.5%, intraabdominal collection/sepsis 2.2%). PTI had 21.7% morbidity (obstruction 14.4%, anemia 11.0%, hemorrhage 1.5%, perforation 0.6%, adverse events requiring surgery 15.8%). NRS resulted in 10.6% perioperative mortality and 21.7% morbidity (major 7.9%, minor 21.7%, reoperation 0.1%).

 

Conclusions

PTR in patients with incurable colorectal cancer results in a limited improvement of survival without a significant increase in morbidity. PTR should be considered by the multidisciplinary team on an individual patient basis.

 

URL https://rdcu.be/bFAuP

 


 

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