Featured Articles in Mar 2021

Dorothea Liebermann-Meffert (*1930: †2020)—A Life Dedicated to Surgery

 

Author list: H. J. Stein

Abstract: N/A

 

URL: https://rdcu.be/cd3MB

 


Transoral Thyroidectomy: Safety and Outcomes of 200 Consecutive North American Cases

 

Author list:
Jonathon O. Russell, Christopher R. Razavi, Mohammad Shaear, Rui H. Liu, Lena W. Chen, Pia Pace-Asciak, Ved Tanavde, Katherine Y. Tai, Khalid Ali, Akeweh Fondong, Hoon Yub Kim & Ralph P. Tufano


Abstract:

Background

North American adoption of the transoral endoscopic thyroidectomy vestibular approach (TOETVA) has been limited due to concerns regarding the generalizability of published outcomes, as data are predominantly from Asian cohorts with a different body habitus. We describe our experience with TOETVA in a North American population in the context of the conventional transcervical approach thyroidectomy (TCA).

 

Study design

Cases of TOETVA and TCA were reviewed from August 2017 to March 2020 at a tertiary care center. Outcomes included operative time, major (permanent recurrent laryngeal nerve (RLN) injury, permanent hypoparathyroidism, hematoma, conversion to open surgery), and minor complications. The TOETVA cohort was stratified into body mass index (BMI) classes of underweight/normal < 25 kg/m2, overweight 25–29.9 kg/m2, and obese ≥ 30 kg/m2 for comparative analysis. Multivariable logistic regression analyses were performed for odds of cumulative complication.

 

Results

Two hundred TOETVA and 333 TCA cases were included. There was no difference in incidence of major complications between the TOETVA and TCA cohorts (1.5% vs. 2.1%, p = 0.75). No difference was found in the rate of temporary RLN injury (4.5% vs. 2.1%, p = 0.124) or temporary hypoparathyroidism (18.2% vs. 12.5%, p = 0.163) for TOETVA and TCA, respectively. Surgical technique (TOETVA vs TCA) did not alter the odds of cumulative complication (OR 0.69 95% CI [0.26–1.85]) on logistic regression analysis. In the TOETVA cohort, higher BMI did not lead to a significantly greater odds of cumulative complication, 0.52 (95% CI [0.17–1.58]) and 1.69 (95% CI [0.74–3.88]) for the overweight and obese groups, respectively.

 

Conclusion

TOETVA can be performed in a North American patient population without a difference in odds of complication compared to TCA. Higher BMI is not associated with greater likelihood of complication with TOETVA.


URL: https://rdcu.be/cd3MD

 


Short- and Long-Term Outcomes of Transabdominal Preperitoneal, Open Mesh Plug and Open Tissue Inguinal Hernia Repair

 

 

Author list:
Yuichi Takayama, Yuji Kaneoka, Atsuyuki Maeda, Takamasa Takahashi, Muneyasu Kiriyama & Kazuaki Seita

Abstract:

Background

There have been few comparisons of the postoperative outcomes of transabdominal preperitoneal (TAPP), open mesh plug (mesh plug) and open tissue (tissue) hernia repair. The objectives of this study were to compare these repair methods.

 

Methods

This was a retrospective study of 1813 inguinal hernia patients between January 2008 and December 2016. Of these patients, 474 underwent TAPP repair, 1293 underwent mesh plug repair, and 46 underwent tissue repair. The short-term and long-term outcomes determined by questionnaire were compared among the three groups. In addition, risk factors for patient dissatisfaction were assessed.

 

Results

In the TAPP group, the postoperative complications rate was the lowest at 4.6% (7.4% and 6.5% in the mesh plug and the tissue groups, respectively, P = 0.07), and recurrence rate was lower compared to the mesh plug group (0.8% vs. 3.3%, P = 0.002). As long-term outcomes, 92%, 88% and 75% of patients were satisfied in the TAPP, mesh plug and tissue groups, respectively (P = 0.03). The rate of patients with numbness was 3.1% in the TAPP group, 5.2% in the mesh plug group and 14% in the tissue group (P = 0.04). Predictive independent risk factors for patient dissatisfaction were complications (OR: 3.99, 95% CI: 1.35–11.8, P = 0.012) and infection (OR: 16.9, 95% CI: 1.25–229, P = 0.003).

 

Conclusions

TAPP repair is superior to mesh plug and tissue repairs in terms of complications, satisfaction and numbness, as determined by questionnaire. Complications and infection were independently associated with the patient dissatisfaction.


URL: https://rdcu.be/cd3MP        

 


Preventable Morbidity and Mortality Among Non-trauma Emergency Surgery Patients

 

Author list:
Constantine S. Velmahos, Nikolaos Kokoroskos, Constantine Tarabanis, Haytham M. Kaafarani, Sanjay Gupta & Charudutt N. Paranjape


Abstract:

Background

Preventable morbidity and mortality among emergency surgery patients is not adequately analyzed. We aim to describe and classify preventable complications and deaths in this population.

 

Methods

The medical records and quality control documents of patients with emergency, non-trauma, surgical disease admitted between September 1, 2006, and August 31, 2018, and recorded to have a preventable or potentially preventable morbidity and mortality were reviewed. The primary outcome was a classification of the complications and deaths by a panel of experts, as attributable to issues of personal performance or system deficiencies.

 

Results

One hundred and fifty patients were identified (127 complications and 23 deaths). The most commonly encountered preventable complications were surgical-site infection (17%), bleeding (13%), injury to adjacent structures (12%), and anastomotic leak (8%). The majority of complications seemed to stem from personal performance (97%), due to either technical or judgment issues, and only 3% were linked with system flaws, either in the form of communication or inadequate protocols. Alcohol use disorder and duration of operation were different between patients with preventable adverse events related to technical issues and patients related to judgment issues; furthermore, more patients who experienced judgment issues died during hospital stay (p <0.05).

 

Conclusion

Among emergency surgery patients, who suffer preventable complications and deaths, issues related to personal performance are more frequent than system flaws. Whereas the effort to improve systems should be unwavering, the emphasis on the surgeon’s personal responsibility to avoid preventable complications should not be derailed.


URL: https://rdcu.be/cd3MR

 


COVID: Maintaining Standards in Colorectal Cancer Surgery During the Global Pandemic: A Cohort Study

 

Author list:
Julia Merchant, Ian Lindsey, David James, Nick Symons, Stephen Boyce, Oliver Jones, Bruce George & Chris Cunningham

Abstract:

Aim

Cancer surgery in the COVID-19 pandemic presents many new challenges. For each patient, the risk of contracting COVID-19 during the perioperative period, with the potential for life-threatening sequelae (1), has to be weighed against the risk of delaying treatment. We assessed the response and short-term outcomes from elective colorectal cancer surgery during the pandemic at our institution.

 

Method

We report a prospective cohort study of all elective colorectal surgery cases performed at our Trust during the 11 weeks following the national UK lockdown on 23rd March 2020, compared with the same time period in 2019.

 

Results

Eighty-five colorectal operations were performed during the 2020 (COVID) time period, and 179 performed in the 2019 (non-COVID) time period. A significantly higher proportion of cases during the COVID period were cancer-related (66% vs 26%, p < 0.00001). There was no difference in length of hospital stay, complications or readmissions. There were no mortalities in either cohort. Among the cancer patients, there were no differences in TMN staging, R1 resection rate or lymph node yields. No elective patient tested positive for COVID-19 during the perioperative period.

 

Conclusion

At the height of the COVID pandemic, we maintained delivery the of high-quality elective colorectal cancer surgery, with no worsening of short-term outcomes and no compromise in the quality of cancer resections. Ongoing monitoring of this cohort is essential. The risks associated with COVID-19 will continue for some time, necessitating adaptive responses to maintain high-quality cancer services.

 


URL: https://rdcu.be/cd3MY

 


We asked the Experts:Reducing Opioid Prescription After Abdominal Surgery; A Place for Nerve Block and Wound Infiltration

 

Author list:
Sameh Hany Emile & Medhat Mikhail Messeha  


Abstract:  N/A


URL:  https://rdcu.be/cd3M0

 


My First Paper: Peri-operative Mortality Following Cholecystectomy in Australia: Potential Preventability of Adverse Events

 

Author list:

Laure Taher Mansour, Sean Brien, Jessica Reid & Guy J. Maddern


Abstract:
Background

Cholecystectomy is a commonly performed procedure; however, it is not without risks. It is crucial to constantly audit surgical outcomes in order to improve quality of care. The aim of this retrospective population-based cohort study is to identify preventable issues of clinical management associated with adverse occurrences in order to reduce mortality of cholecystectomy patients.

 

Methods

Data were obtained from the Australian and New Zealand Audit of Surgical Mortality (ANZASM). It encompasses peer-reviewed first and second line assessments of management of cholecystectomy patients who died from 2005 to 2015 in Australia. Clinical Management Issues (CMIs) were identified from text in assessments and grouped into communication failures, pre-operative, intra-operative and post-operative categories. These were further classified into subthemes using thematic analysis with a data-driven approach.

 

Results

There were 359 deaths in the study period. CMIs were present in 71 cases, with a reported total of 124 concerns or adverse events. Post-operative CMIs were the most prevalent issue [50% (62/124)], with the most common theme being delay to recognise complications (19/124). Pre-operative concerns were the second most common (n = 34). Decision to operate was questioned in 14 cases, and delay to surgery was reported in 12 cases.

 

Conclusion

ANZASM analysis has allowed us to identify modifiable adverse occurrences. This audit shows that delay to recognise complications is the most common assessment recorded. Preventive measures should be taken to improve outcomes and reduce peri-operative mortality, with an emphasis on post-operative management and enhancing communication between members of the multidisciplinary team.

 

URL: https://rdcu.be/cd3Nm

 


Systematic Reviews and Meta-Analyses: Clinical and Organizational Impact of the AIRSEAL® Insufflation System During Laparoscopic Surgery: A Systematic Review

 

Author list:
David Balayssac, Marie Selvy, Anthony Martelin, Caroline Giroudon, Delphine Cabelguenne & Xavier Armoiry

Abstract:
Several low-impact laparoscopic strategies have been developed to improve the safety of pneumoperitoneum. We conducted a systematic review to establish the current evidence base for the use of the AIRSEAL® insufflation device for low-pressure pneumoperitoneum in laparoscopic surgery. We searched the literature using several electronic databases, for studies with comparative design published in the English language from January 2010 to April 2020. The population of interest included patients with any type of health condition who underwent laparoscopic surgery using the AIRSEAL® insufflation system or a standard CO2 insufflator. Ten studies (four randomized clinical trials/six non-randomized clinical trials), that enrolled 1394 participants in total who underwent urology, gynaecology or abdominal surgeries, were included. Total complication rates were similar between groups. Only three studies evaluated the impact of the insufflation system on post-operative pain, and showed inconsistent benefit of AIRSEAL® (significant decrease in pain in two studies, no difference in one). The same was observed in the two sole studies in which pain killers consumption was measured (significant decrease in morphine consumption 24 h after surgery in one study, no difference in the other). Operative duration was significantly shorter with AIRSEAL® in three studies. For both post-operative room and total length of stay, there was no difference between groups. No studies reported economic outcomes. Current literature supports the feasibility of the AIRSEAL® system during laparoscopic surgery but more studies are required to establish the added clinical benefit and to explore the preferences of physicians and patients.

 

URL: https://rdcu.be/cd3Nq


Determinants of Breast-Conserving Therapy in the Asian Population: A Systematic Review

 

Author list:
Maria Paz Galeano Machuca, Shelly Chien-Chien Cheng, Tony Hong-Ting Jou & Chih-Tao Cheng  

Abstract:
Background

Treatment guidelines recommend breast-conserving therapy (BCT) for patients with early-stage breast cancer. However, Asian patients choose mastectomy over BCT, and the factors influencing this choice are unknown. This review aimed to identify the factors most frequently reported in the Eastern and Southeastern Asian population influencing the choice of BCT for treatment of early-stage breast cancer.

 

Methods

PRISMA guidelines were followed, and PubMed and EMBASE databases were used. The literature search initially identified 4619 articles; abstract screening and full-text screening were performed on 150 and 19 articles, respectively, and 9 articles were finally included in the study.

 

Results

Selection of BCT was associated with sociodemographic factors, such as high socioeconomic status and education level and young age at diagnosis; clinicopathological factors, such as small tumor size and mammographically detected tumors; and healthcare provider factors, such as treatment from a female doctor or from a breast specialist. However, not selecting BCT was associated with personal factors, such as fear of recurrence and avoidance of further treatment.

 

Conclusions

The process of making a treatment decision is complicated and involves many factors influencing patients’ choice of surgery type. Exploring these factors helps to elucidate why patients do not choose BCT as their treatment option.

 

 

URL: https://rdcu.be/cd3ND


 

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