Featured Articles in May 2021

The World Journal of Surgery Announces Rowan Parks of Scotland as a New Associate Editor

 

Author: Julie Ann Sosa

Abstract: Announcement. No Abstract.

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Firearm Deaths are Increasing and Endemic in the USA: It is a Problem of Suicides and Not Homicides Mesh Infection

 

 

Authors: Peter Rhee, Kartik Prabhakaran, Bellal Joseph, Abbas Smiley, Kenji Okumura, Joshua Klein,
Anthony Policastro, Gary Lombardo & Rifat Latifi

Abstract:

Background

To analyze and report on the changes in epidemiology traumatic causes of death in the USA.

Methods

Data were extracted from the annual National Vital Statistics Reports (2008–2017) from Center for Disease Control and analyzed for trends during the time period given. Generalized additive model was applied to evaluate the significance of trend using R software.

Results

Firearm deaths (39,790) and firearm death rate (12.2/100,000) in 2017 were the highest reported, and this increasing trend was significant (p < 0.001) the last ten years. Deaths from motor vehicle crash (MVC) and firearm homicides did not change significantly during the same time period. Firearm deaths were lower than MVC deaths by 21% (8,197/39,790) in 2008, but after 10 years, the difference was only 1% (458/40,231). Years of life lost from firearms is now higher than MVC. Suicides by firearm in 2017 were the highest reported at 23,854/39,773 (60%). In 2017, suicides by firearm victims were predominantly white 20,328/23,562 (85%), men 20,362/23,562 (86%), and the largest group was between the ages of 55–64.

Conclusions

Death from firearms in the USA is increasing and endemic. They were the highest ever reported in 2017 by the CDC. While deaths from MVC used to be the main cause of traumatic death in the USA, deaths from firearms now almost equal it. Calculated years of life lost from firearms is now more than from MVC. Most firearm deaths are not from homicides but are from suicides, and they are predominantly in white older males of the baby boomer generation (born 1946–1964).

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Racial and Ethnic Disparities in Frail Geriatric Trauma Patients

 

Authors: Tanya Anand, Muhammad Khurrum, Mohamad Chehab, Letitia Bible, Samer Asmar, Molly
Douglas, Michael Ditillo, Lynn Gries & Bellal Joseph

Abstract:

Background

Frailty in geriatric trauma patients is commonly associated with adverse outcomes. Racial disparities in geriatric trauma patients are previously described in the literature. We aimed to assess whether race and ethnicity influence outcomes in frail geriatric trauma patients.

Methods

We performed a 1-year (2017) analysis of TQIP including all geriatric (age ≥ 65 years) trauma patients. The frailty index was calculated using 11-variables and a cutoff limit of 0.27 was defined for frail status. Multivariate regression analysis was performed to control for demographics, insurance status, injury parameters, vital signs, and ICU and hospital length of stay.

Results

We included 41,111 frail geriatric trauma patients. In terms of race, among frail geriatric trauma patients, 35,376 were Whites and 2916 were African Americans; in terms of ethnicity, 37,122 were Non-Hispanics and 2184 were Hispanics. On regression analysis, the White race was associated with higher odds of mortality (OR, 1.5; 95% CI, 1.2–2.0; p < 0.01) and in-hospital complications (OR, 1.4; 95% CI, 1.1–1.9; p < 0.01). White patients were more likely to be discharged to SNF (OR, 1.2; 95% CI, 1.1–1.4; p = 0.03) and less likely to be discharged home (p = 0.04) compared to African Americans. Non-Hispanics were more likely to be discharged to SNF (OR, 1.3; 95% CI, 1.1–1.5; p < 0.01) and less likely to be discharged home (p < 0.01) as compared to Hispanics. No significant difference in in-hospital mortality was seen between Hispanics and Non-Hispanics.

Conclusion

Race and ethnicity influence outcomes in frail geriatric trauma patients. These disparities exist regardless of age, gender, injury severity, and insurance status. Further studies are needed to highlight disparities by race and ethnicity and to identify potentially modifiable risk factors in the geriatric trauma population.

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Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society

 

Authors: Carol J. Peden, Geeta Aggarwal, Michael Scott

Abstract:

Background

Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach.

Methods

Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1—Preoperative Care and Part 2—Intraoperative and Postoperative management. This paper provides guidelines for Part 1.

Results

Twelve components of preoperative care were considered. Consensus was reached after three rounds.

Conclusions

These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.

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We Asked the Experts: The WHO Surgical Safety Checklist and the COVID-19 Pandemic: Recommendations for Content and Implementation Adaptations

 

Authors: Nikhil Panda, James C. Etheridge, Takshveer Singh, Yves Sonnay, George Molina, Barbara K. Burian, Nina Capo-Chichi, Christy E. Cauley, David A. H. de Beer, Miliard Derbew, Roger D. Dias, Mary C. Fearon, Mekdes Daba Feyssa, Kathryn Hagen, Manoj Kumar, Tihitena Negussie Mammo, Edward R. Mariano, Alan Merry, Barbara Mushayandebvu, Mary T. Nabukenya, Milind Shah, Lisa Spruce, Thomas G. Weiser & Mary E. Brindle

 

Abstract:

 

Background

As surgical systems are forced to adapt and respond to new challenges, so should the patient safety tools within those systems. We sought to determine how the WHO SSC might best be adapted during the COVID-19 pandemic.

 

Methods

18 Panelists from five continents and multiple clinical specialties participated in a three-round modified Delphi technique to identify potential recommendations, assess agreement with proposed recommendations and address items not meeting consensus.

 

Results

From an initial 29 recommendations identified in the first round, 12 were identified for inclusion in the second round. After discussion of recommendations without consensus for inclusion or exclusion, four additional recommendations were added for an eventual 16 recommendations. Nine of these recommendations were related to checklist content, while seven recommendations were related to implementation.

 

Conclusions

This multinational panel has identified 16 recommendations for sites looking to use the surgical safety checklist during the COVID-19 pandemic. These recommendations provide an example of how the SSC can adapt to meet urgent and emerging needs of surgical systems by targeting important processes and encouraging critical discussions.

 

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Humanitarian Surgical Missions in Times of COVID-19: Recommendations to Safely Return to a Sub-Saharan Africa Low-Resource Setting

 

Authors: Víctor Lopez-Lopez, Ana Morales, Elisa García-Vazquez, Miguel González, Quiteria Hernandez, Alberto Baroja-Mazo, Dolores Palazon, Jose A. Tortosa, Maria A. Rodriguez, Nuria M. Torregrosa, Winnie Kanyi, J. K. Ndungu, José Gil Martinez & José M. Rodriguez

 

 

 

Abstract:

 

Background

Since the declaration of the pandemic, humanitarian medicine has been discontinued. Until now, there have been no general recommendations on how humanitarian surgical missions should be organized.

 

Methods

Based on our experience in the field of humanitarian surgical missions to Sub-Saharan Africa, a panel of recommendations in times of COVID-19 was developed. The fields under study were as follows: (1) Planning of a multidisciplinary project; (2) Organization of the infrastructure; (3) Screening, management and treatment of SARS-COV-2; (4) Diagnostic tests for SARS-COV-2; (5) Surgical priorization and (6) Context of patients during health-care assistance. We applied a risk bias measurement to obtain a consensus among humanitarian health-care providers with experience in this field.

 

Results

A total of 94.36% of agreement were reached for the approval of the recommendations. Emergency surgery must be a priority, and elective surgery adapted. For emergency surgery, we established a priority level 1a (< 24 h) and 1b (< 72 h). For an elective procedure, according our American College of Surgeon adaptation score, process with more than 60 points should be reconsidered. Due to the low life expectancy in many African countries, we consider 45–50 years as age of risk. In case of SARS-COV-2 active infection or high clinical suspicion, the screening, management and treatment should be following the international guidelines adapted to duration of the stay, available infrastructure, size of the cooperation team and medical resources.

 

Conclusions

Humanitarian surgical mission in times of COVID-19 is a challenge that must extrapolate the established recommendations to the local cooperation environment.

 

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My First Paper: Prophylactic Mesh After Midline Laparotomy: Evidence is out There, but why do Surgeons Hesitate?

 

Authors: Martijn Depuydt, Mathias Allaeys, Luis Abreu de Carvalho, Aude Vanlander & Frederik Berrevoet

Abstract:

Background

Incisional hernias have an impact on patients’ quality of life and on health care finances. Because of high recurrence rates despite mesh repair, the prevention of incisional hernias with prophylactic mesh reinforcement is currently a topic of interest. But only 15% of surgeons are implementing it, mainly because of fear for mesh complications and disbelief in the benefits. The goal of this systematic review is to evaluate the effectiveness and safety of prophylactic mesh in adult patients after midline laparotomy.

Methods

An extensive literature search was performed in PubMed, Embase and CENTRAL until 9/5/2020 for RCTs and cohort studies regarding mesh reinforcement versus primary suture closure of a midline laparotomy. The quality of the articles was analyzed using the Scottish Intercollegiate Guidelines Network checklists. Revman 5 was used to perform a meta-analysis.

Results

Twenty-three articles were found with a total of 1633 patients in the mesh reinforcement group and 1533 in the primary suture group. An odds ratio for incisional hernia incidence of 0.37 (95% CI = [0.30, 0.46], p < 0.01) with RCTs and of 0.15 (95% CI = [0.09,0.25], p < 0.01) in cohort studies was calculated. Seroma rate shows a significant odds ratio of 2.18 (95% CI = [1.45, 3.29], p < 0.01) in favor of primary suture. No increase was found regarding other complications.

Conclusion

The evidence for the use of prophylactic mesh reinforcement is overwhelming with a significant reduction in incisional hernia rate, but implementation in daily clinical practice remains limited. Instead of putting patients at risk for incisional hernia formation and subsequent complications, surgeons should question their arguments why not to use mesh reinforcement, specifically in high-risk patients.

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My First Paper: Gender-Based Microaggressions in Surgery: A Scoping Review of the Global Literature

 

 

Authors: Holly N. Sprow, Nathaniel F. Hansen, Hannah E. Loeb, Caroline L. Wight, Rolvix H. Patterson, Dominique Vervoort, Eliana E. Kim, Raphael Greving, Adelina Mazhiqi, Kathryn Wall, Jacquelyn Corley, Emily Anderson & Kathryn Chu

Abstract:

Background

In addition to systemic gender disparities, women in surgery encounter interpersonal microaggressions. The objective of this study is to describe the most common forms of microaggressions reported by women in surgery.

Methods

We conducted a scoping review using PubMed/MEDLINE, Ovid, and Web of Science to describe the international, indexed English-language literature on gender-based microaggressions experienced by female surgeons, surgical trainees, and medical students in surgery. After screening by title, abstract, and full-text, 37 articles were retained for data extraction and analysis. Microaggressions were analyzed using the Sexist Microaggression Experience and Stress Scale (MESS) framework and stratified by country of origin.

Results

Gender-based microaggression publications most commonly originated from the United States (n = 27 articles), Canada (n = 3), and India (n = 2). Gender-based microaggressions were classified into environmental invalidations (n = 20), being treated like a second-class citizen (n = 18), assumptions of traditional gender roles (n = 12), sexual objectification (n = 11), assumptions of inferiority (n = 10), being forced to leave gender at the door (n = 8), and experiencing sexist language (n = 6). Additionally, attendings were more frequently reported to experience microaggressions than surgical trainees and medical students, but more articles reported data on attendings (n = 16) than surgical trainees (n = 10) or students (n = 4).

Conclusion

While recent advancements have opened the field of surgery to women, there is still a lack of female representation, and persistent microaggressions may perpetuate this gender disparity. Addressing microaggressions against female surgeons is essential to achieving gender equity in surgical practice.

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