The Ombuds for Diversity, Equity, and Inclusion as an Essential Addition to the WJS
Author list: Sanziana Roman & Julie Ann Sosa
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Welcome Adam Gyedu of Ghana as a New Associate Editor
Author list: Julie Ann Sosa
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Succeeding in Continuing Trauma Education During a Pandemic
Ilan Y. Mitchnik & Avraham I. Rivkind
Corona virus disease 2019 (Covid-19) impacted continuing medical education programs such as the Advanced Trauma Life Support (ATLS) course. Modifications made to medical training like teleconferencing could affect students’ learning success. We sought to evaluate the effects of the American College of Surgeons modifications on success rates in passing the ATLS course.
This study evaluated 28 ATLS 10th edition courses educating 898 students at our region before and after Covid-19 modifications. Traditional two-day courses were performed in-person while modified courses were conducted with a one-day teleconference followed by a second in-person practical day. We compared the characteristics and course pass rates between the traditional and modified ATLS courses.
Modified ATLS courses had significantly lower pass rates (81.0%; 95% confidence interval = [74.8–87.3]) compared to traditional ATLS courses (94.3%; [92.2–96.3]).
Modifications to the ATLS course are associated with lower student pass. This is possibly due to ineffective knowledge consolidation. Better modifications to the course are required such as use of electronic learning tools with modification to course schedule or returning to the traditional course but with the use of Covid-19 vaccines and other protective measures. These suggestions should be considered and evaluated further by ATLS program leaders.
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My First Paper: Impact of the COVID-19 Pandemic on Pediatric Surgical Volume in Four Low- and Middle-Income Country Hospitals
Paul Park, Ruth Laverde, Greg Klazura, Ava Yap, Bruce Bvulani, Bertille Ki, Toussaint W. Tapsoba, Emmanuel A. Ameh, Maryrose Osazuwa, Michele Ugazzi, José Daza, Emma Bryce, David Cunningham & Doruk Ozgediz
Abstract - Background
The impact of the COVID-19 pandemic on surgical care delivery in low- and middle-income countries (LMIC) has been challenging to assess due to a lack of data. This study examines the impact of COVID-19 on pediatric surgical volumes at four LMIC hospitals.
Retrospective and prospective pediatric surgical data collected at hospitals in Burkina Faso, Ecuador, Nigeria, and Zambia were reviewed from January 2019 to April 2021. Changes in surgical volume were assessed using interrupted time series analysis.
6078 total operations were assessed. Before the pandemic, overall surgical volume increased by 21 cases/month (95% CI 14 to 28, p < 0.001). From March to April 2020, the total surgical volume dropped by 32%, or 110 cases (95% CI − 196 to − 24, p = 0.014). Patients during the pandemic were younger (2.7 vs. 3.3 years, p < 0.001) and healthier (ASA I 69% vs. 66%, p = 0.003). Additionally, they experienced lower rates of post-operative sepsis (0.3% vs 1.5%, p < 0.001), surgical site infections (1.3% vs 5.8%, p < 0.001), and mortality (1.6% vs 3.1%, p < 0.001).
During the COVID-19 pandemic, children’s surgery in LMIC saw a sharp decline in total surgical volume by a third in the month following March 2020, followed by a slow recovery afterward. Patients were healthier with better post-operative outcomes during the pandemic, implying a widening disparity gap in surgical access and exacerbating challenges in addressing the large unmet burden of pediatric surgical disease in LMICs with a need for immediate mitigation strategies.
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Safety and Feasibility of Robotic Transaxillary Thyroidectomy for Graves’ Disease
Mohammed Saad Bu Bshait, Jin Kyong Kim, Cho Rok Lee, Sang-Wook Kang, Jong Ju Jeong, Kee-Hyun Nam & Woong Youn Chung
Abstract - Background
Despite the increase in experience and understanding of robotic thyroidectomy, its application for Graves’ disease (GD) remains controversial. This study aimed to assess the safety and feasibility of robotic transaxillary thyroidectomy (RTT) for GD in comparison with the conventional open thyroidectomy (open group: OG) approach.
A total of 192 patients who underwent surgical resection for GD were retrospectively reviewed. Among them, 51 patients underwent RTT and the remaining 141 patients were in the conventional OG.
All robotic operations were performed successfully without open conversion. Patients who underwent RTT were significantly younger (P < 0.001) and predominantly of the female sex. Operative time was longer for RTT than for the OG (182.5 ± 58.1 vs. 112.0 ± 29.5; P < 0.001). The mean intraoperative blood loss was not statistically different between RTT and the OG (113.3 ± 161.6 vs. 95.3 ± 209.1, P = 0.223). The mean weight of the resected thyroid was reduced in those who underwent RTT compared with open thyroidectomy (P = 0.033). The overall complication rate for RTT and open thyroidectomy was not significantly different (33.3% vs. 22.7%, P = 0.135). In RTT, the most common complication was transient hypocalcemia (21%). Permanent hypocalcemia and recurrent laryngeal nerve injury occurred in only one patient in each group. The weight of the resected thyroid was not related to the incidence of complications in patients receiving RTT.
Considering excellent cosmesis, findings of this study support the safety and feasibility of RTT. Nevertheless, it should be performed by expert surgeons with extensive robotic surgery experience.
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Incidence and Contemporary Management of Delayed Bleeding Following Pancreaticoduodenectomy
Joseph R. Habib, Shanshan Gao, Ahn Joon Young, Elie Ghabi, Aslam Ejaz, William Burns, Richard Burkhart, Matthew Weiss, Christopher L. Wolfgang, John L. Cameron, Robert Liddell, Christos Georgiades, Kelvin Hong, Jin He & Kelly J. Lafaro
Delayed bleeding after pancreaticoduodenectomy (PD) is a life-threatening complication. However, the optimal management remains unclear. We summarize our experience of the management of delayed bleeding after PD and define the outcomes associated with different types of management.
All patients who underwent a PD between January 1987 and June 2020 at Johns Hopkins University were retrospectively reviewed. Delayed bleeding was defined as bleeding on or after postoperative day 5 following PD. Incidence, outcomes, and trends were reported.
Among the 6201 patients that underwent PD, delayed bleeding occurred in 130 (2.1%) at a median of 12 days (IQR: 9, 24) postoperation. The pattern of bleeding was classified as intraluminal (51.5%), extraluminal (40.8%), and mixed (7.7%). A clinically relevant postoperative pancreatic fistula and an intraabdominal abscess preceded the delayed bleeding in 43.1% and 31.5% of cases, respectively. Arterial pseudoaneurysm or bleeding from peripancreatic vessels was the most common reason (54.6%) with the gastroduodenal artery being the most common source (18.5%). Endoscopy, angiography, and reoperation were performed as a first-line approach in 35.4%, 52.3%, and 6.2% of patients, respectively. The overall mortality was 16.2% and decreased over the study period (p < 0.01).
Delayed bleeding following PD remains a life-threatening complication. The most common location of delayed bleeding is from the gastroduodenal artery. Angiography with embolization should be the initial approach for urgent bleeding with surgical re-exploration reserved for unstable patients or failed control of bleeding after interventional angiography or endoscopy.
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Surgical Outcomes in Canada and the United States: An Analysis of the ACS-NSQIP Clinical Registry
Peter Cram, Mark E. Cohen, Clifford Ko, Bruce E. Landon, Bruce Hall & Timothy D. Jackson
Abstract - Background
There has been longstanding uncertainty over whether lower healthcare spending in Canada might be associated with inferior outcomes for hospital-based care. We hypothesized that mortality and surgical complication rates would be higher for patients who underwent four common surgical procedures in Canada as compared to the US.
Design, Setting, and Participants
We conducted a retrospective cohort study of all adults who underwent hip fracture repair, colectomy, pancreatectomy, or spine surgery in 96 Canadian and 585 US hospitals participating in the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) between January 1, 2015 and December 31, 2019. We compared patients with respect to demographic characteristics and comorbidity. We then compared unadjusted and adjusted outcomes within 30-days of surgery for patients in Canada and the US including: (1) Mortality; (2) A composite constituting 1-or-more of the following complications (cardiac arrest; myocardial infarction; pneumonia; renal failure/; return to operating room; surgical site infection; sepsis; unplanned intubation).
Our hip fracture cohort consisted of 21,166 patients in Canada (22.3%) and 73,817 in the US (77.7%), for colectomy 21,279 patients in Canada (8.9%) and 218,307 (91.1%), for pancreatectomy 873 (7.8%) in Canada and 12,078 (92.2%) in the US, and for spine surgery 14,088 (5.3%) and 252,029 (94.7%). Patient sociodemographics and comorbidity were clinically similar between jurisdictions. In adjusted analyses odds of death was significantly higher in Canada for two procedures (colectomy (OR 1.22; 95% CI 1.044–1.424; P = .012) and pancreatectomy (OR 2.11; 95% CI 1.26–3.56; P = .005)) and similar for hip fracture and spine surgery. Odds of the composite outcome were significantly higher in Canada for all 4 procedures, largely driven by higher risk of cardiac events and post-operative infections.
We found evidence of higher rates of mortality and surgical complications within 30-days of surgery for patients in Canada as compared to the US.
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Inspirational Women in Surgery: Dr Samantha Pillay, FRACS (Urologist, South Australia)
Savio George Barreto
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Inspirational Women in Surgery:: Hildegunde Piza-Katzer; Professor Emeritus of Plastic and Reconstructive Surgery in Austria
Selman Uranues & Hubert Hauser
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Bariatric Surgery is Effective and Safe for Obese Patients with Compensated Cirrhosis: A Systematic Review and Meta-Analysis
Jie Bai, Zhe Jia, Yu Chen, Yongguo Li, Sujun Zheng & Zhongping Duan
Abstract - Background
With the global pandemic of obesity and nonalcoholic fatty liver disease (NAFLD), the incidence of cirrhosis associated with nonalcoholic steatohepatitis (NASH) has greatly increased. This study aimed to evaluate the efficacy and safety of bariatric surgery in obese cirrhotic patients.
PubMed, EMBASE, and the Cochrane Library were searched for relevant studies. Effectiveness outcomes were weight loss, remission of comorbidities, and improvement in liver function. Safety outcomes were procedural complications and mortality.
A total of 15 studies were included in this meta-analysis. Patients with compensated cirrhosis lost weight significantly after surgery, and the percentage of excess weight loss was 60.44 (95% CI, 44.34 to 76.55). Bariatric surgery resulted in remission of NAFLD in 57.9% (95% CI, 27.5% to 88.3%), T2DM in 58.4% (95% CI, 48.4% to 68.4%), hypertension in 53.1% (95% CI, 43% to 63.3%), dyslipidemia in 59.8% (95% CI, 41.1% to 78.5%) of patients with cirrhosis. Bariatric surgery reduced the levels of alanine aminotransferase and aspartate aminotransferase. The incidence of surgical complications in patients with cirrhosis was about 19.2% (95% CI, 11.7% to 26.6%), which was higher than that in patients without cirrhosis (OR 2.67 [95% CI, 1.26 to 5.67]). Patients with cirrhosis had an overall mortality rate of 1.3%, and the mortality rates for compensated cirrhosis and decompensated cirrhosis were 0.9% and 18.2%, respectively.
Bariatric surgery is effective for weight loss, remission of comorbidities, and reversal of liver damage. Although cirrhotic patients have a higher risk of complications and death, bariatric surgery is relatively safe for well-compensated cirrhosis.
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Omental Procedures During Peritoneal Dialysis Insertion: A Systematic Review and Meta-Analysis
Jin K. Kim, Marisol Lolas, Daniel T. Keefe, Mandy Rickard, Priyank Yadav, Jessica M. Ming, Karen Milford, Martin A. Koyle, Armando J. Lorenzo & Michael E. Chua
Abstract - Objectives
Peritoneal dialysis (PD) is an option for ultrafiltration for patients with end-stage renal disease. Once placed, PD catheters may malfunction often due to omental wrapping. Omental procedures such as omentectomy and omentopexy may reduce this risk. This investigation aims to perform a systematic review and meta-analysis of the literature on the role of omental procedures on PD catheter insertions.
Following protocol registration on PROSPERO (CRD42020218950), a systematic review was performed in accordance with the Cochrane Collaboration. A literature search was performed in February 2021 across Medline, EMBASE, Scopus, and Cochrane Library. Records with patients who underwent PD catheter insertion with and without omental manipulation were included. The records underwent screening, full-text review, and data extraction. Study qualities were assessed using RoBINS-I and RoB2. Effect estimates were extracted as risk ratios and corresponding 95% confidence intervals (CI) were pooled using inverse variance method with random-effect model.
Of 510 records identified, 15 studies were included in the meta-analysis (1 RCT, 2 prospective, 12 retrospective). With omental procedures, there was decreased the likelihood of failure requiring removal of PD catheter (RR 0.47, 95% CI 0.38, 0.58) and PD catheter obstruction (RR 0.23, 95% CI 0.14, 0.39); there was no difference in likelihood of catheter malposition or migration (RR 0.87, 95% CI 0.23, 3.29) or peritonitis (RR 0.74, 95% CI 0.40, 1.35).
Based on the current low to moderate quality of evidence, omental manipulation at the time of PD catheter insertion confers benefits of decreased obstruction and failure requiring removal.
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Quality of Life in Patients with Benign Non-Toxic Goiter After Surgical Intervention: A Systematic Review and Meta-Analysis
Natalia Chaves, M. Juanita Rodriguez, Jordan M. Broekhuis, Hao Wei Chen, Paul A. Bain & Benjamin C. James
Abstract - Background
Prior studies evaluating health-related quality of life (HR-QoL) outcomes in patients undergoing surgery for benign non-toxic goiter have used different instruments and time points, leading to conflicting results. We sought to systematically review the differences in HR-QoL among patients with BNTG at baseline and 6 months after surgery, using exclusively the ThyPRO questionnaire.
A systematic search was performed using PubMed, Embase, Web of Science, Cochrane Central, CINAHL, and PsycINFO for papers reporting the assessment of HR-QoL utilizing ThyPRO. Data were meta-analyzed using a random-effects model, and pooled estimates were calculated using weighted mean differences (WMD) between baseline and 6 months after surgery. We assessed the quality and risk of bias of the studies using the Robins-I tool and previously published minimally important change (MIC) values to assess clinical significance.
Six papers met the predefined inclusion criteria, describing a total of 496 patients. Meta-analysis demonstrated improved QoL in all thirteen domains of ThyPRO six months post-surgical intervention compared to baseline. Specifically, the largest improvement in QoL was seen in the domains of overall QoL, WMD −25.84 (95% CI −29.70, −21.98, p < 0.001, I2 = 23%), goiter symptoms, 23.96 (95% CI −30.29, −17.64, p < 0.001, I2 = 91%), and tiredness, −16.20 (95% CI −19.23, −13.16, p < 0.001, I2 = 3%). The differences in scores 9 of 13 domains were clinically significant based on MIC.
Disease-specific HR-QoL improved in all ThyPRO domains after surgery in patients with BNTG. Future studies of QoL in thyroid surgery patients will benefit from a standard questionnaire and improved reporting of covariates including complications to ensure comparability across studies.
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