COVID19: - Is There Still a Place for Scheduled Surgery? Reflection from Pathophysiological Data
Author list - Emmanuel Besnier, Jean-Jacques Tuech & Lilian Schwarz
How Can We Troubleshoot Loss of Intraoperative Nerve Monitoring During Head and Neck Surgery?
Author list- Jina Kim & Sanziana A. Roman
URL - https://rdcu.be/b3Op0
Everyone Has Their Role to Play During WHO Surgical Safety Checklist
Author list - Christina Taplin, Linda Romano, Mark Tacey & Russell Hodgson
The World Health Organisation Surgical Safety Checklist (SSC) is a mandated part of surgical practice. Adherence to the SSC has been shown to result in improved patient outcomes. The aim of this study was to determine the current adherence to the timeout section of the SSC and, in particular, the function of individual team members.
A prospective pre- and post-intervention observational audit was conducted on the timeout section. The intervention involved an in-hospital display of interim results and distribution to theatre staff. Data were collected on participants, duration and compliance with checklist items for 400 theatre cases. There were 200 cases before and after the intervention.
There were no cases in which the timeout section was completed correctly in its entirety. Post-intervention, there was a significant improvement in participation of theatre staff (excluding surgeons) as well as a significant improvement in items discussed and documented. Discussion of items such as anticipated critical events, pressure areas and the team introduction remained low. Some items on the checklist were discussed significantly more when a particular staff member participated.
Observed completion rates of the timeout section of the SSC were poor. Individual team members positively influenced checklist items more aligned to their role, highlighting the importance of timeout being performed by the entire theatre team. Improved performance was seen following audit and feedback.
URL - https://rdcu.be/b3Op2
Successful Implementation of a Trauma and Acute Care Surgery Model in Ecuador
Author list - Doris Sarmiento Altamirano, Amber Himmler, Oscar Chango Sigüenza, Raúl Pino Andrade, Nube Flores Lazo, Jeovanni Reinoso Naranjo, Hernán Sacoto Aguilar, Lenin Fernández de Córdova, Edgar Rodas, Juan Carlos Puyana & Juan Carlos Salamea Molina
For years, surgical emergencies in Ecuador were managed on a case-by-case basis without significant standardization. To address these issues, the Regional Hospital Vicente Corral Moscoso adapted and implemented a model of “trauma and acute care surgery” (TACS) to the reality of Cuenca, Ecuador.
A cohort study was carried out, comparing patients exposed to the traditional model and patients exposed to the TACS model. Variables assessed included number of surgical patients attended to in the emergency department, number of surgical interventions, number of surgeries performed per surgeon, surgical wait time, length of stay and in-hospital mortality.
The total number of surgical interventions increased (3919.6–5745.8, p ≤ 0.05); by extension, the total number of surgeries performed per surgeon also increased (5.37–223.68, p ≤ 0.05). We observed a statistically significant decrease in surgical wait time (10.6–3.2 h for emergency general surgery, 6.3–1.6 h for trauma, p ≤ 0.05). Length of stay decreased in trauma patients (9–6 days, p ≤ 0.05). Higher mortality was found in the traditional model (p ≤ 0.05) compared to the TACS model.
The implementation of TACS model in a resource-restrained hospital in Latin America had a positive impact by decreasing surgical waiting time in trauma and emergency surgery patients and length of stay in trauma patients. We also noted a statistically significant decrease in mortality. Savings to the overall system and patients can be inferred by decreased mortality, length of stay and surgical wait times. To our knowledge, this is the first implementation of a TACS model described in Latin America.
URL - https://rdcu.be/b3Op7
Adrenalectomy for Primary Aldosteronism: Variability in Work-up Strategies and Low Guideline Adherence Worldwide
Author list - Wessel M. C. M. Vorselaars, Dirk-Jan van Beek, Diederik P. D. Suurd, Emily Postma, Wilko Spiering, Inne H. M. Borel Rinkes, Gerlof D. Valk, Menno R. Vriens & International CONNsortium
Various diagnostic tests are available to establish the primary aldosteronism (PA) diagnosis and to determine the disease laterality. Combined with the controversies in the literature, unawareness of guidelines and technical demands and high costs of some of these diagnostics, this could lead to significant differences in work-up strategies worldwide. Therefore, we investigated the work-up before surgery for PA in daily clinical practice within a multicenter study.
Patients who underwent unilateral adrenalectomy for PA within 16 centers in Europe, Canada, Australia and the USA between 2010 and 2016 were included. We did not exclude patients based on the performed diagnostic tests during work-up to make our data representative for current clinical practice. Adherence to the Endocrine Society Guideline and variables associated with not performing adrenal venous sampling (AVS) were analyzed.
In total, 435 patients were eligible. An aldosterone-to-renin ratio, confirmatory test, computed tomography (CT), magnetic resonance imaging and AVS were performed in 82.9%, 32.9%, 86.9%, 17.0% and 65.3% of patients, respectively. A complete work-up, as recommended by the guideline, was performed in 13.1% of patients. Bilateral disease or normal adrenal anatomy on CT (OR 16.19; CI 3.50–74.99), smaller tumor size on CT (OR 0.06; CI 0.04–0.08) and presence of hypokalemia (OR 2.00; CI 1.19–3.32) were independently associated with performing AVS.
This study is the first to examine the daily clinical practice work-up of PA within a worldwide cohort of surgical patients. The results demonstrate significant variability in work-up strategies and low adherence to The Endocrine Society guideline.
URL - https://rdcu.be/b3Op9
The Obesity Paradox in the Trauma Patient
Author list - J. E. Dvorak, E. L. W. Lester, P. J. Maluso, L. Tatebe, V. Schlanser, M. Kaminsky, T. Messer, A. J. Dennis, F. Starr & F. Bokhari
The obesity paradox is the association of increased survival for overweight and obese patients compared to normal and underweight patients, despite an increased risk of morbidity. The obesity paradox has been demonstrated in many disease states but has yet to be studied in trauma. The objective of this study is to elucidate the presence of the obesity paradox in trauma patients by evaluating the association between BMI and outcomes.
Using the 2014–2015 National Trauma Database (NTDB), adults were categorized by WHO BMI category. Logistic regression was used to assess the odds of mortality associated with each category, adjusting for statistically significant covariables. Length of stay (LOS), ICU LOS and ventilator days were also analyzed, adjusting for statistically significant covariables.
A total of 415,807 patients were identified. Underweight patients had increased odds of mortality (OR 1.378, p < 0.001 95% CI 1.252–1.514), while being overweight had a protective effect (OR 0.916, p = 0.002 95% CI 0.867–0.968). Class I obesity was not associated with increased mortality compared to normal weight (OR 1.013, p = 0.707 95% CI 0.946–1.085). Class II and Class III obesity were associated with increased mortality risk (Class II OR 1.178, p = 0.001 95% CI 1.069–1.299; Class III OR 1.515, p < 0.001 95% CI 1.368–1.677). Hospital and ICU LOS increased with each successive increase in BMI category above normal weight. Obesity was associated with increased ventilator days; Class I obese patients had a 22% increase in ventilator days (IRR 1.217 95% CI 1.171–1.263), and Class III obese patients had a 54% increase (IRR 1.536 95% CI 1.450–1.627).
The obesity paradox exists in trauma patients. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance patient care.
URL - https://rdcu.be/b3Oqfc
Adult Presentations of Congenital Midgut Malrotation: A Systematic Review
Author list - Jonathan J. Neville, Jack Gallagher, Anuja Mitra & Hemant Sheth
Adult midgut malrotation is a rare cause of an acute abdomen requiring urgent intervention. It may also present in the non-acute setting with chronic, non-specific symptoms. The objective of this study is to identify the clinical features, appropriate investigations and current surgical management associated with adult malrotation.
A systematic review was conducted according to PRISMA guidelines, identifying confirmed cases of adult malrotation. Patient demographics, clinical features, investigation findings and operative details were analysed.
Forty-five reports met the inclusion criteria, totalling 194 cases. Mean age was 38.9 years (n = 92), and 52.3% were male (n = 130). The commonest presenting complaints were abdominal pain (76.8%), vomiting (35.1%) and food intolerance (21.6%). At least one chronic symptom was reported in 87.6% and included intermittent abdominal pain (41.2%), vomiting (12.4%) and obstipation (11.9%). Computerised tomography scanning was the most frequent imaging modality (81.4%), with a sensitivity of 97.5%. The whirlpool sign was observed in 30.9%; abnormalities of the superior mesenteric axis were the commonest finding (58.0%). Ladd’s procedure was the most common surgical intervention (74.5%). There was no significant difference in resolution rates between emergency and elective procedures (p = 0.46), but length of stay was significantly shorter for elective cases. (p = 0.009). There was no significant difference in risk of mortality, or symptom resolution, between operative and conservative management (p = 0.14 and p = 0.44, respectively).
Malrotation in the adult manifests with chronic symptoms and should be considered as a differential diagnosis in patients with abdominal pain, vomiting and food intolerance.
URL - https://rdcu.be/b3Oqh