Featured Articles in May 2018

Memories of the Future

 

Author list: Marco G. Patti 

 

Abstract:

The International Society of Surgery (ISS; also known as Societe’ Internationale de Chirugie) is the oldest international surgical society in the world. The first congress of the ISS was held in Brussels in 1905, and Dr. Emil Theodore Kocher was the first ISS president: 4 years later, he would be awarded the Nobel Prize for his work on the physiology, pathology, and surgery of the thyroid. The ISS has members in almost every country in the world, and today in Basel we have about 1800 participants from 93 countries.

 

URL: https://rdcu.be/MFwI

 


The Physician Attrition Crisis: A Cross-Sectional Survey of the Risk Factors for Reduced Job Satisfaction Among US Surgeons

 

Author list: Theresa N. Jackson, Chris P. Pearcy, Zhamak Khorgami, Vaidehi Agrawal, Kevin E. Taubman, Michael S. Truitt

 

Abstract:

Background

A physician shortage is on the horizon, and surgeons are particularly vulnerable due to attrition. Reduced job satisfaction leads to increased job turnover and earlier retirement. The purpose of this study is to delineate the risk factors that contribute to reduced job satisfaction.

 

Methods

A cross-sectional survey of US surgeons was conducted from September 2016 to May 2017. Screening for job satisfaction was performed using the abridged Job in General scale. Respondents were grouped into more and less satisfied using the median split. Twenty-five potential risk factors were examined that included demographic, occupational, psychological, wellness, and work-environment variables.

 

Results

Overall, 993 respondents were grouped into more satisfied (n = 502) and less satisfied (n = 491) cohorts. Of the demographic variables, female gender and younger age were associated with decreased job satisfaction (p = 0.003 and p = 0.008). Most occupational variables (specialty, experience, academics, practice size, payment model) were not significant. However, increased average hours worked correlated with less satisfaction (p = 0.008). Posttraumatic stress disorder, burnout, wellness, all eight work-environment variables, and unhappiness with career choice were linked to reduced job satisfaction (p = 0.001).

 

Conclusion

A surgeon shortage has serious implications for health care. Job satisfaction is associated with physician retention. Our results suggest women and younger surgeons may be at increased risk for job dissatisfaction. Targeted work-environment interventions to reduce work-hours, improve hospital culture, and provide adequate financial reimbursement may promote job satisfaction and wellness.

 

URL: https://rdcu.be/MFxo

 


Mesh Versus Patch Repair for Epigastric and Umbilical Hernia (MORPHEUS Trial); One-Year Results of a Randomized Controlled Trial

 

Author list: J. E. H. Ponten, B. J. M. Leenders, W. K. G. Leclercq, T. Lettinga, J. Heemskerk, J. J. M. Konsten, P. S. S. Castelijns, S. W. Nienhuijs

 

Abstract:

Background

This trial is a randomized controlled, patient-blinded, multicentre, superiority trial.

 

Methods

All patients ≥18 years with a single, symptomatic and primary umbilical or epigastric hernia (

 

Results

A total of 352 patients were randomized in this trial; 348 patients received the intervention (n = 177 PVP vs. n = 171 mesh). No peri-operative complications occurred. PVP placement was significantly faster compared to mesh placement (30 min, SD 11 vs. 35 min, SD 11) and was scored as an easier procedure. At 1-month follow-up, 76 patients suffered any kind of complication. There was no significant difference in the proportion of complications (24.9% for PVP and 18.7% for mesh, p = 0.195). A significant difference was seen in re-operation rate within 1 month, significantly less early re-operations in the mesh group (0.0 vs. 2.8%, p = 0.027). After 1-year follow-up, no significant differences are seen in recurrence rates (n = 13, 7.8% PVP vs. n = 5, 3.3% mesh, p = 0.08).

 

Conclusion

Both mesh and PVP had a comparable amount of reported complications. There was a significantly higher incidence of early re-operations due to early complications in the PVP group. No differences were seen in infection rates and the need for antibiotic treatment. No significant difference was seen in the recurrence rates.

 

URL: https://rdcu.be/MFyD

 


Oncological Safety and Technical Feasibility of Nipple-Sparing Mastectomy for Breast Cancer: The Hong Kong Experience

 

Author list: Yolanda Ho-Yan Chan, Wai-Ming Yau, Polly Suk-Yee Cheung

 

Abstract:

Background

Nipple-sparing mastectomy (NSM) has gained widespread popularity in recent years. Nonetheless, patient selection, technical consideration and oncological safety of its extension to breast cancer treatment remain uncertain. Few publications have reviewed the application of NSM in Asian populations.

 

Methods

We retrospectively reviewed 91 women with malignant breast tumours, who underwent 97 NSM in Hong Kong Sanatorium and Hospital from 2009 to 2015. Breast cancer patients who required mastectomy and opted for immediate reconstruction were considered for NSM if they showed no obvious nipple involvement clinically. All breast specimens were subjected to intraoperative pathological examination of the retroareolar tissue to exclude occult tumour infiltration before the final decision of nipple–areola complex (NAC) preservation. Clinical parameters, tumour characteristics and oncological outcomes were analyzed.

 

 

 

 

Results

Carcinoma of the breast accounts for 99.0% of our indications for therapeutic NSM. Almost all NSM were accompanied with immediate reconstruction. Abnormal pathology was shown in retroareolar tissue of ten patients (10.3%), and seven of these NAC were excised due to tumour involvement detected by intraoperative frozen section. Six (6.2%) NSM were complicated with superficial epidermolysis. Yet, there was no delayed NAC excision because of nipple necrosis. Overall NAC preservation rate reached 92.8%. Local and/or distant recurrences occurred in four patients (4.1%) after a mean follow-up of 20.6 months. One NAC recurrence was documented.

 

Conclusions

Our series support the oncological safety of NSM after exclusion of neoplastic NAC involvement preliminarily by intraoperative frozen section and definitively by final pathology. Its technical feasibility is well proven by the low nipple necrosis rate.

 

URL: https://rdcu.be/MFzk

 


Outcomes of Emergency Laparotomy (EL) Care Protocol at Tertiary Care Center from Low–Middle-Income Country (LMIC)

 

Author list: Nitin Vashistha, Dinesh Singhal, Sandeep Budhiraja, Bharat Aggarwal, Raj Tobin, Kamal Fotedar

 

Abstract:

Background

Emergency laparotomy mortality ranges between 10 and 20% in best of Western healthcare systems and is currently a major focus for quality improvement programs. In contrast, emergency surgery scenario in LMIC is largely undefined, often neglected and complex (large burden of diseases but only limited capacity for adequate treatment). We evaluated the efficacy of ‘EL care protocol’ aimed at cost-effective optimal utilization of best available local expertise and infrastructure.

 

Methods

One hundred and two consecutive adult patients (≥16 years) who underwent EL from December 2012–December 2015 at a private tertiary hospital were retrospectively analyzed. The patients who underwent emergency laparoscopic procedures were excluded from the analysis. The EL care protocol included. (1) Admission to surgical intensive care unit for pre- and postoperative optimization. (2) Preferred radiologic investigation: abdominal computed tomography (CT) scan. (3) Surgery and critical care by senior surgical gastroenterologists and internists/anesthesiologists, respectively. Outcome measures were procedure-related complications (Clavien–Dindo classification), readmissions and costs.

 

Results

Of the 102 patients, there were 62 males and 40 females with median age of 60 (range 16–93) years. There were no complications in 22 (21.6%) patients, while Clavien–Dindo complications grade I or II occurred in 48 (47%) patients. Grade V Clavien–Dindo complications and the 30-day mortality were similar of 19 (18.6%). The readmission rate was 8 (7.8%). The expected mortality for the study group by P-POSSUM score was 31.2 (30.6%). The ratio (O/E) of observed to expected mortality was 0.61. The all inclusive median cost of treatment was INR 379,255 ($5590).

 

Conclusion

LMIC centers should develop their own center-specific EL care protocols to improve outcomes of EL.

 

URL: https://rdcu.be/MFzY

 


Medullary Thyroid Carcinoma: Survival Analysis and Evaluation of Mutation-Specific Immunohistochemistry in Detection of Sporadic Disease

 

Author list: S. Jayakody, J. Reagh, M. Bullock, A. Aniss, R. Clifton-Bligh, D. Learoyd, B. Robinson, L. Delbridge, S. Sidhu, A. J. Gill, M. Sywak

 

Abstract:

Background

Medullary thyroid cancer (MTC) is a rare tumour of neuroendocrine origin with a more aggressive profile than differentiated thyroid cancer. Familial cases of MTC are associated with RET mutations whilst RAS mutations appear to be a frequent finding in RET negative tumours. The aims of this study were to analyse survival outcomes in MTC and to evaluate the role of RAS immunohistochemistry in the identification of sporadic disease.

 

Methods

A retrospective cohort study of consecutive patients with MTC was undertaken. The primary outcome measures were overall survival and disease-free survival. Survival analysis was performed on the basis of sporadic and familial disease. Patients had routine RET testing using the capillary (Sanger) sequencing method. Histopathological MTC slides from 100 patients were tested for HRASQ61R, a common somatic RAS mutation in MTC, with mutation-specific immunohistochemistry (IHC).

 

Results

A total of 195 patients had surgical treatment of MTC in the period 1980 to 2016. There were 83 males and 112 females with a mean age of 53.0 years. A total of 39 (20%) patients had familial disease. Sporadic cases had a higher median pre-op calcitonin (969.5 vs. 257.5 pg/ml), greater mean primary tumour size (23.5 vs. 12.5 mm) and more distant metastases (12.8 vs. 10.3%). Multivariate analysis showed age (p = 0.005), Multiple Endocrine Neoplasia Type 2 (MEN2) status (p = 0.021) and distant metastasis (p = 0.002) to be significant independent predictors of survival. Significant independent predictors for disease-free survival were age (p = 0.015), MEN2 (p = 0.002), pre-op calcitonin (p = 0.033) and venous invasion (p = 0.001). The overall 5-year survival was 100% for familial MTC and 78% for sporadic MTC. The 10-year disease-free survival was 94% for familial MTC and 61% for sporadic cases. A total of 100 cases of MTC underwent mutation-specific IHC for HRASQ61R. Of these, 18 had confirmed MEN2. IHC had 100% specificity in excluding MEN2. Twelve (12%) of 100 patients stained positive for HRASQ61R mutation.

 

Conclusions

In the era of genetic testing, RET status significantly influences disease-specific survival in MTC. Mutation-specific IHC for HRASQ61R may have a role in the identification of patients presenting with sporadic disease.

 

URL: https://rdcu.be/MFAW

 


Impact of Trauma System Structure on Injury Outcomes: A Systematic Review and Meta-Analysis

 

Author list: Lynne Moore, Howard Champion, Pier-Alexandre Tardif, Brice-Lionel Kuimi, Gerard O’Reilly, Ari Leppaniemi, Peter Cameron, Cameron S. Palmer, Fikri M. Abu-Zidan, Belinda Gabbe, Christine Gaarder, Natalie Yanchar, Henry Thomas Stelfox, Raul Coimbra, John Kortbeek, Vanessa K. Noonan, Amy Gunning, Malcolm Gordon, Monty Khajanchi, Teegwende V. Porgo, Alexis F. Turgeon, Luke Leenen

 

 

 

 

 

Abstract:

Background

The effectiveness of trauma systems in decreasing injury mortality and morbidity has been well demonstrated. However, little is known about which components contribute to their effectiveness. We aimed to systematically review the evidence of the impact of trauma system components on clinically important injury outcomes.

 

Methods

We searched MEDLINE, EMBASE, Cochrane CENTRAL, and BIOSIS/Web of Knowledge, gray literature and trauma association Web sites to identify studies evaluating the association between at least one trauma system component and injury outcome. We calculated pooled effect estimates using inverse-variance random-effects models. We evaluated quality of evidence using GRADE criteria.

 

Results

We screened 15,974 records, retaining 41 studies for qualitative synthesis and 19 for meta-analysis. Two recommended trauma system components were associated with reduced odds of mortality: inclusive design (odds ratio [OR] = 0.72 [0.65–0.80]) and helicopter transport (OR = 0.70 [0.55–0.88]). Pre-Hospital Advanced Trauma Life Support was associated with a significant reduction in hospital days (mean difference [MD] = 5.7 [4.4–7.0]) but a nonsignificant reduction in mortality (OR = 0.78 [0.44–1.39]). Population density of surgeons was associated with a nonsignificant decrease in mortality (MD = 0.58 [−0.22 to 1.39]). Trauma system maturity was associated with a significant reduction in mortality (OR = 0.76 [0.68–0.85]). Quality of evidence was low or very low for mortality and healthcare utilization.

 

Conclusions

This review offers low-quality evidence for the effectiveness of an inclusive design and trauma system maturity and very-low-quality evidence for helicopter transport in reducing injury mortality. Further research should evaluate other recommended components of trauma systems and non-fatal outcomes and explore the impact of system component interactions.

 

URL: https://rdcu.be/MEa8

 


 

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