Featured Articles in Nov 2019

Do Ice Packs Reduce Postoperative Midline Incision Pain, NSAID or Narcotic Use? (Awarded the Grassi Prize, WCS 2019 Krakow, Poland)

 

Author list 

Bharadhwaj Ravindhran, Sendhil Rajan, Gayatri Balachandran, L. N. Mohan

 

Abstract

Background

Adequate postoperative analgesia, especially after major abdominal surgery is important for recovery, early mobility, and patient satisfaction. We aimed to study the effects of cryotherapy via an ice pack in the immediate postoperative period, for patients undergoing major abdominal operations.

 

Methods

This prospective study was conducted at our tertiary care referral center in a low–middle-income country setting. The preoperative patient characteristics, intra-operative variables, and postoperative outcomes were compared between two sets of patients. Cryotherapy was delivered via frozen gel packs for 24 h immediately following laparotomy. Pain relief was assessed with visual analog pain scores (VAS). Comparisons between groups were measured by Chi-square test, Fischer’s exact test, or Mann–Whitney U test as appropriate.

 

Results

Sixty-eight patients were included in the study: 33 in the cryotherapy group and 35 in the non-cryotherapy group. Mean postoperative pain scores (VAS) were significantly lower in the cryotherapy group versus the control group (3.97 ± 0.6 vs. 4.9 ± 0.7 on postoperative day (POD) 1; p <  0.001, and 3 ± 0.5 vs. 09 ± 0.8 on POD2; p < 0.001). The median narcotic use in morphine equivalents was lesser in the cryotherapy group from POD 1–3 (66 (IQR-16) vs. 89 (IQR-17); p = 0.001). No significant difference was seen in the NSAID use between the groups. The cryotherapy group was also found to have a lesser incidence of surgical site infection (p = 0.03) and better lung function based on incentive spirometry (p = 0.01) and demonstrated earlier functional recovery based on their ability to perform the sit-to-stand test (p = 0.001).

 

Conclusion

Ice packs are a simple, cost-effective adjuvant to standard postoperative pain management which reduce pain and narcotic use and promote early rehabilitation.

 

 

 


When is It Safe to Start VTE Prophylaxis After Blunt Solid Organ Injury?

 

Author list 

Morgan Schellenberg, Kenji Inaba, Subarna Biswas, Patrick Heindel, Elizabeth Benjamin, Aaron Strumwasser, Kazuhide Matsushima, Lydia Lam, Demetrios Demetriades

 

Abstract

Background

The optimal timing of VTE prophylaxis initiation after blunt solid organ injury is controversial. Retrospective studies suggest initiation ≤48 h is safe. This prospective study examined the safety and efficacy of early VTE prophylaxis initiation after nonoperative blunt solid organ injury.

 

Methods

All patients >15 years of age presenting after blunt trauma (12/01/16–11/30/17) were prospectively screened. Patients were included if solid organ injury (liver, spleen, kidney) was diagnosed on admission CT scan and nonoperative management was planned. ED deaths, transfers, patients with pre-existing bleeding disorders or home antiplatelet/anticoagulant medications, and those who did not receive VTE prophylaxis were excluded. Demographics, injury/clinical data, type/timing of VTE prophylaxis initiation, and outcomes were collected. Patients were dichotomized into study groups based on VTE prophylaxis initiation time: Early (≤48 h) vs Late (>48 h after admission). Prophylaxis initiation was at the discretion of the attending trauma surgeon. The primary study outcome was VTE event rate. Secondary outcomes included hospital length of stay (LOS), intensive care unit (ICU) LOS, need for and volume of post-prophylaxis blood transfusion, need for delayed (post-prophylaxis) interventional radiology (IR) or operative intervention, failure of nonoperative management, and mortality. Outcomes were compared with univariate analysis. Multivariate analysis with logistic regression determined independent predictors of late VTE prophylaxis initiation.

 

Results

After exclusions, 118 patients were identified. Median ISS was 22 [IQR 14–26]. Median AAST grade of injury was 2 [IQR 2–3] for liver, 2 [IQR 1–3] for spleen, and 3 [IQR 2–3] for kidney. Compared to late prophylaxis patients (n = 57, 48%), early prophylaxis patients (n = 61, 52%) had significantly fewer DVTs (n = 0, 0% vs n = 5, 9%, p = 0.024) but similar rates of PE (n = 2, 3% vs n = 3, 5%, p = 0.672). TBI was the only significant risk factor for late prophylaxis (OR 0.22, p = 0.015). No patient in either group required delayed intervention (operative or IR) for bleeding. There was no difference in volume of post-prophylaxis blood transfusion.

 

Conclusions

In this prospective study of patients with nonoperative blunt solid organ injuries, early (≤48 h) initiation of VTE prophylaxis resulted in a lower incidence of DVTs without an associated increase in bleeding or need for intervention. Early initiation of VTE prophylaxis is likely to be safe and beneficial for patients with blunt solid organ injury.

 

 


Postoperative Long-Term Outcomes in Elderly Patients with Gastric Cancer and Risk Factors for Death from Other Diseases

 

Author list 

Tadayoshi Hashimoto, Yukinori Kurokawa, Jota Mikami, Tsuyoshi Takahashi, Yasuhiro Miyazaki, Koji Tanaka, Tomoki Makino, Makoto Yamasaki, Masaaki Motoori, Yutaka Kimura, Kiyokazu Nakajima, Masaki Mori, Yuichiro Doki

 

Abstract

Background

Elderly patients with gastric cancer are frequently treated surgically in current clinical practice. Although several studies have investigated short-term outcomes after gastrectomy in elderly patients, most did not evaluate long-term outcomes.

 

Methods

We analyzed 1154 consecutive patients who underwent curative gastrectomy for gastric cancer between 2001 and 2013. We classified them into two groups: the elderly group (n = 241), consisting of patients aged ≥75 years, and the non-elderly group (n = 913), consisting of patients aged <75 years, and compared the short- and long-term outcomes between the two groups. The risk factors for death from other diseases in elderly patients were also examined.

 

Results

Although the incidence of postoperative pneumonia was significantly higher in the elderly group (P < 0.001), the proportion of overall postoperative complications did not differ significantly between the two groups (P = 0.097). The disease-specific survival was similar between the two groups (P = 0.743), whereas the overall survival in the elderly group was significantly shorter than that in the non-elderly group (P < 0.001) because of a higher incidence of death from other diseases throughout all gastric cancer stages. Multivariate analysis revealed that a low preoperative prognostic nutrition index (PNI) and multiple comorbidities were significant risk factors for death from other diseases within 5 years in the elderly group.

 

Conclusions

Despite acceptable short-term outcomes, long-term outcomes in elderly patients with gastric cancer were poor due to the high incidence of death from other diseases. Indications for surgery in elderly patients with a low PNI or multiple comorbidities should be considered carefully.

 

 


Pancreatectomy with Hepatic Artery Resection for Pancreatic Head Cancer

 

Author list 

Feng Yang, Xiaoyi Wang, Chen Jin, Hang He, Deliang Fu

 

Abstract

Background

To report our experiences and outcome of pancreatectomy with hepatic artery resection (PT-HAR) for advanced pancreatic head cancer.

 

Methods

A retrospective study of clinical data from 14 patients with advanced pancreatic ductal adenocarcinoma undergoing PT-HAR in a tertiary academic center between March 2010 and June 2017 was performed. Furthermore, a comparison in a match-pair analysis (1:3) with patients received standard pancreatectomy during the same period was conducted to evaluate the clinical outcome.

 

Results

The PT-HAR cohort included pancreaticoduodenectomy (n = 11) and total pancreatectomy (n = 3). Of them, six underwent portal/superior mesenteric vein resection and reconstruction and three underwent hepatic artery reconstruction. Four patients without arterial reconstruction developed liver perfusion failure. No perioperative mortality occurred, with a median postoperative hospital stay of 10.5 days (range 6–39). The median overall survival was 30 months (95% confidence interval 9.8–50.2 months), with the 1-, 2-, and 3-year survival rates of 81.8%, 63.6%, and 42.4%, respectively. The matched-pair data analysis showed no significant differences between PT-HAR and standard pancreatectomy, except that liver perfusion failure occurred more frequently after PT-HAR.

 

Conclusions

PT-HAR can be performed with acceptable morbidity, mortality, and survival for advanced pancreatic head cancer. Considering the potential risk of liver perfusion failure, only highly selected patients are eligible for PT-HAR without reconstruction.

 

 


Global Surgery: A 30-Year Bibliometric Analysis (1987–2017)

 

Author list 

Alessandro Sgrò, Ibrahim S. Al-Busaidi, Cameron I. Wells, Dominique Vervoort, Sara Venturini, Valeria Farina, Federica Figà, Francesc Azkarate, Ewen M. Harrison, Francesco Pata

 

Abstract

Introduction

There has been a growing interest in addressing the surgical disease burden in low- and middle-income countries (LMICs). Assessing the current state of global surgery research activity is an important step in identifying gaps in knowledge and directing research efforts towards important unaddressed issues. The aim of this bibliometric analysis was to identify trends in the publication of global surgical research over the last 30 years.

 

Methods

Scopus® was searched for global surgical publications (1987–2017). Results were hand-screened, and data were collected for included articles. Bibliometric data were extracted from Scopus® and Journal Citation Reports. Country-level economic and population data were obtained from the World Bank. Descriptive statistics were used to summarise data and identify significant trends.

 

Results

A total of 1623 articles were identified. The volume of scientific production on global surgery increased from 14 publications in 1987 to 149 in 2017. Similarly, the number of articles published open access increased from four in 1987 to 68 in 2017. Observational studies accounted for 88.7% of the included studies. The three most common specialties were obstetrics and gynaecology 260 (16.0%), general surgery 256 (15.8%), and paediatric surgery 196 (12.1%). Over two times as many authors were affiliated to an LMIC institution than to a high-income country (HIC) institution (6628, 71.5% vs 2481, 28.5%, P < 0.001). A total of 965 studies (59.5%) were conducted entirely by LMIC authors, and 534 (32.9%) by collaborations between HICs and LMICs.

 

Conclusion

The quantity of research in global surgery has substantially increased over the past 30 years. Authors from LMICs seemed the most proactive in addressing the global surgical disease burden. Increasing the funding for interventional studies, and therefore the quality of evidence in surgery, has the potential for greater impact for patients in LMICs.

 

 


Learning Curve in Laparoscopic Liver Resection, Educational Value of Simulation and Training Programmes: A Systematic Review

 

Author list 

Théophile Guilbaud, David Jérémie Birnbaum, Stéphane Berdah, Olivier Farges, Laura Beyer Berjot

 

Abstract

Background

The laparoscopic approach is widely accepted as the procedure of choice for abdominal surgery. However, laparoscopic liver resection (LLR) has advanced slowly due to the significant learning curve (LC), and only few publications have dealt with advanced training in LLR.

 

Methods

Two reviewers conducted systematic research through MEDLINE and EMBASE with combinations of the following keywords: (learning curve OR teaching OR training OR simulation OR education) AND (liver OR hepatic) AND (laparoscopic OR laparoscopy). Robotic-assisted, hand-assisted and hybrid LLRs were excluded.

 

Results

Nineteen studies were retrieved. Overall, the level of evidence was low. Thirteen articles assessed the LC during real-life LLR, and six articles focussed on simulation and training programmes in LLR. The LC in minor LLR comprised 60 cases overall, and 15 cases for standardised left lateral sectionectomy. For major LLR (MLLR), the LC was 50 cases for most studies, but was reported to be 15–20 cases in more recent studies, provided MLLR is performed progressively in selected patients. However, there was heterogeneity in the literature regarding the number of minor LLRs required before MLLR, with 60 minor LLRs reported as the minimum. Six studies showed a potential benefit of simulation and training programmes in this field. The gradual implementation of LLR combined with simulation-based training programmes could reduce the clinical impact of LC.

 

Conclusions

The LC in LLR is a long process, and MLLR should be gradually implemented under the supervision of experienced surgeons. Training outside the operating room may reduce the LC in real-life situations.

 

 


Perioperative Fluid Restriction in Abdominal Surgery: A Systematic Review and Meta-analysis

 

Author list 

Yanfei Shen, Guolong Cai, Shijin Gong, Jing Yan

 

Abstract

Background

Perioperative fluid management is a critical component in patients undergoing abdominal surgery. However, the benefit of restricted fluid regimen remains inconclusive. This systematic review aimed to explore potential factors causing these inconsistent findings.

 

Methods

The literature searches were performed in three databases including PubMed, Embase, and the Cochrane library until August 30, 2018. Only randomized, controlled trials comparing the effect of restricted versus liberal regimen in abdominal surgery were included. The primary outcome was total postoperative complications. Subgroup analysis was performed according to between-group weight increase difference (≥ 2 kg and < 2 kg) and fluid intake ratio (≥ 1.8 and < 1.8).

 

Results

Sixteen studies were finally included in this meta-analysis. The benefit of the restricted regimen in reducing postoperative complication was only significant in the subgroup with high weight increase difference (≥ 2 kg) (RR 0.67, 95% CI 0.57–0.79) and the subgroup with high fluid intake ratio (≥ 1.8) (RR 0.72, 95% CI 0.62–0.82). In the subgroup with low weight increase difference (< 2 kg) or low fluid intake ratio (< 1.8), the effect of the restricted regimen was not significant (RR 0.88, 95% CI 0.51–1.50, and RR 1.18, 95% CI 0.91–1.53, respectively).

 

Conclusions

The benefit of the restricted regimen was only significant in the subgroup with high weight increase difference (≥ 2 kg) or high fluid intake ratio (≥ 1.8).

 

 


Prophylactic Negative Pressure Wound Therapy in Closed Abdominal Incisions: A Meta-analysis of Randomised Controlled Trials

Author list 

Cameron I. Wells, Chathura B. B. Ratnayake, Jenni Perrin, Sanjay Pandanaboyana

 

Abstract

Introduction

Negative pressure wound therapy (NPWT) may prevent subcutaneous fluid accumulation in a closed wound and subsequently reduce surgical site infections (SSI). This meta-analysis aimed to determine the effect of prophylactic NPWT on SSI incidence following abdominal surgery.

 

Methods

A systematic search of MEDLINE and EMBASE databases was performed using PRISMA methodology. All randomised trials reporting the use of NPWT in closed abdominal incisions were included, regardless of the type of operation. The primary outcome measure was the incidence of SSI, stratified by superficial and deep and organ/space infections. Secondary outcomes were wound dehiscence and length of hospital stay.

 

Results

Ten randomised trials met the inclusion criteria (five Caesarean, five midline laparotomy). The use of NPWT reduced overall SSI (11.6% vs. 16.7%, RR 0.67, 95% CI 0.48–0.95, p = 0.02). The rate of superficial SSI rate was also reduced (6.3% vs. 11.3%, RR 0.57, 95% CI 0.35–0.94, p = 0.03). There was no effect on deep or organ/space SSI (3.2% vs. 4.2%, RR 0.77, 95% CI 0.51–1.18, p = 0.23), wound dehiscence (9.7% vs. 10.9%, RR 0.92, 95% CI 0.69–1.21, p = 0.54), or length of hospital stay (MD 0.06 days, 95% CI–0.11 to 0.23, p = 0.51).

 

Conclusions

Prophylactic use of NPWT may reduce the incidence of superficial SSI in closed abdominal incisions but has no effect on deep or organ space SSI.

 


 

BACK