Featured Articles in Oct 2021

Inspiring Women in Surgery: Dr. Sr. Mary Margaret Ajiko, Uganda

 

Author list:  Tamara N. Fitzgerald

 

Abstract:

None.


Free Link: rdcu.be/coXe9


ERAS Protocol Minimizes Intensive Care Unit Utilization and Improves Outcomes Following Pulmonary Resection

 

Author list: Terrance Peng, Kimberly A. Shemanski, Li Ding, Elizabeth A. David, Anthony W. Kim, Michael Kim, Dustin K. Lieu, Sean C. Wightman, Jasmine Zhao & Scott M. Atay

 

 

Abstract:

Background

Enhanced recovery after surgery (ERAS) protocols have been associated with improved postoperative outcomes but require further validation in thoracic surgery. This study evaluated outcomes of patients undergoing pulmonary resection before and after implementation of an ERAS protocol.

 

Methods

Electronic medical records were queried for all patients undergoing pulmonary resection between April 2017 and April 2019. Patients were grouped into pre- and post-ERAS cohorts based on dates of operation. The ERAS protocol prioritized early mobilization, limited invasive monitoring, euvolemia, and non-narcotic analgesia. Primary outcome measures included intensive care unit (ICU) utilization, postoperative pain metrics, and perioperative morbidity. Regression analyses were performed to identify predictors of morbidity. Subgroup analyses were performed by pulmonary risk profile and surgical approach.

 

Results

A total of 64 pre- and 67 post-ERAS patients were included in the study. ERAS implementation was associated with reduced postoperative ICU admission (pre: 65.6% vs. post: 19.4%, p < 0.0001), shorter ICU median length of stay (LOS) (pre: 1 vs. post: 0, p < 0.0001), and decreased opioid usage measured by median morphine milligram equivalents (pre: 40.5 vs. post: 20.0, p < 0.0001). Post-ERAS patients also reported lower visual analog scale (VAS) pain scores on postoperative days (POD) 1 and 2 (pre: 6.3/5.6 vs. post: 5.3/4.2, p = 0.04/0.01) as well as average VAS pain score over POD0-2 (pre: 6.2 vs. post: 5.2, p = 0.005).

 

Conclusions

Implementation of an ERAS protocol for pulmonary resection, which dictated reduced ICU admissions, did not increase major postoperative morbidity. Additionally, ERAS-enrolled patients reported improved postoperative pain control despite decreased opioid utilization.


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Impact of 2016 ERAS Recommendations on Outcomes after Hepatectomy in Cirrhotic and Non-Cirrhotic Patients

Author list: Thibault Lunel, Kayvan Mohkam, Philippe Merle, Aurélie Bonnet, Mathieu Gazon, Paul-Noël Dumont, Christian Ducerf, Jean-Yves Mabrut & Mickaël Lesurtel

 

 

Abstract:

Background

The Enhanced Recovery After Surgery (ERAS) society published new recommendations for hepatectomy in 2016. Few studies have assessed their clinical impact. The aim of this monocentric study was to assess the impact of those guidelines on outcomes after liver surgery with a special focus on cirrhotic patients.

 

Method

Postoperative outcomes of patients undergoing hepatectomy 30 months before and after ERAS implementation according to the 2016 ERAS guidelines were compared after inverse probability of treatment weighting (IPTW). Primary endpoint was 90-day morbidity.

 

Results

From 2015 to 2020, 430 patients underwent hepatectomy including 226 procedures performed before and 204 after ERAS implementation. After IPTW, overall morbidity (42.5% vs. 64.7%, p < 0.001), Comprehensive Complication Index (CCI) score (14.3 vs. 20.8, p = 0.004), length of stay (10.4 vs. 13.7 days, p = 0.001) and textbook outcome (50% vs. 40.2%, p = 0.022) were significantly improved in the ERAS group, while mortality and severe complications were similar in both groups. In the non-cirrhosis subgroup (n = 321), these results were confirmed. However, in the cirrhosis subgroup (n = 105), no difference appeared on outcomes after hepatectomy with an overall morbidity (47.5% vs. 65.2%, p = 0.069) and a length of stay (8 vs. 9 days, p = 0.310) which were not significantly different. The compliance rate to ERAS guidelines was 60% in both cirrhotic and non-cirrhotic subgroups.

 

Conclusion

Perioperative ERAS program for hepatectomy results in improved outcomes with decreased rate of non-severe morbidity. Although those guidelines are not deleterious for cirrhotic patients, they probably require revisions to be more effective in this patient population.


Free Link: https://rdcu.be/cxGy7

 


Accuracy of the Lymph Node Yield in Surgery for Papillary Thyroid Cancer in Children

 

 

Author list: Ava Yap, Amy Shui, Jessica Gosnell, Chiung-Yu Huang, Julie Ann Sosa & Sanziana Roman

 

 

Abstract:

Introduction

Our aim was to determine the accuracy of lymph node yield (LNY) for pediatric patients undergoing thyroidectomy with concurrent lymph nodes harvest for clinically node-negative (cN0) papillary thyroid cancer (PTC).

 

Methods

Patients aged ≤ 18 years with cN0 PTC undergoing thyroidectomy were reviewed in the NCDB, 1998–2016. Demographic and clinical characteristics of patients with ≥ 1 LNY were compared to those without. A truncated beta-binomial distribution estimated the number of lymph nodes needed to detect pathologic nodal positivity, and LNY was calibrated for 90% sensitivity in nodal staging and stratified across clinical tumor size staging (T).

 

Results

1,948 children with cN0 PTC underwent surgical resection; median age was 17 years; 83.2% were female; 47.6% were T1, 25.3% T2, 9.3% T3. 1,272 (65.3%) of these patients had lymph nodes resected, or ≥ 1 LNY. The median LNY was 5 nodes (interquartile range 2–12); 45.9% of patients had ≥ 1 metastatic lymph nodes. In the overall ≥ 1 LNY cohort, 12 nodes (CI 9–19) were needed to predict nodal positivity with > 90% sensitivity. Based on clinical T-stage, detecting a metastatic lymph node with > 90% sensitivity required a LNY of 14 for T1; 8 for T2; 6 for T3.

 

Conclusion

This is the first study estimating the necessary LNY for determining nodal positivity in children with cN0 PTC. The high LNY required in small T1 tumors is likely infeasible and should not be pursued. Accuracy increases with lower LNYs for higher T-stages. Our findings can help guide prognosis and treatment for pediatric patients with PTC.

 

 


Free Link: https://rdcu.be/cxGy9

 


Speaking Up and Speaking Out: Gender Diversity in the Scientific Programme of the RACS Annual Scientific Congress

 

Author list: Christine S. Lai, Jessica Farrar, Fellicia Stanzah, Bradley Crammond, Sandra L. Wong & James C. Lee

 

Abstract:

Background

Disparities in gender representation at medical meetings have been documented despite women representing half of medical school graduating classes. Lack of role models is touted as one of a myriad of factors that perpetuate gender imbalance, particularly in the field of surgery. We evaluated the trend in gender distribution of participants at the Royal Australasian College of Surgeons (RACS) Annual Scientific Congress (ASC) and whether there was a correlation between the gender distribution of the organising committee and speakers and chairpersons invited to attend.

 

Methods

RACS ASC programmes from 2013 to 2018 were retrospectively analysed, examining the gender distribution of speakers, chairpersons and conveners. Trend analysis of distribution was performed, and a generalized linear mixed model was used to investigate the effect of the gender of the conveners on gender of session chairpersons and speakers.

 

Results

Between 2013 and 2018, there were non-significant increases in female speakers invited to speak from 14.9 to 21.7% (p = 0.064) and female conveners appointed from 11 to 19% (p = 0.115), but there was a significant increase in female chairs from 9.6 to 21.6% p < 0.001). Female conveners were 3 times more likely to invite female speakers than male conveners (p < 0.001) and were 20 times more likely to invite female chairs than male conveners (p < 0.001).

 

Conclusion

Visible role models are important in the pursuit of gender equity in surgery in order to break down stereotypes and the hidden curriculum. Intentional effort is required to achieve parity, and such efforts could include appointing more women to organising committees of scientific meetings.

 


Free Link: https://rdcu.be/cxGzv

 


Grit in Surgeons

 

 

Author list: Simone Betchen, Anuja Sarode, Susan Pories & Sharon L. Stein

 

Abstract:

Background

Women in surgery are often told that they are not “tough enough” to be surgeons. A Grit Score provides a validated measure of passion and perseverance, which are aspects of “toughness.”

 

Methods

Survey data were collected from residents and attendings in all surgical fields through multiple surgical societies. Grit and burnout were measured using validated measures.

 

Results

Among surgeons, gender did not have an impact on Grit Score. Burnout had a statistically significant inverse relationship with Grit Score, and women were more likely to report burnout compared to men surgeons.

 

Conclusions

Women in surgery have just as much grit as their male counterparts. Grit should not be a factor in women pursuing a career in surgery.

 


Free Link: https://rdcu.be/cxGzI

 


WATE: The Role of Rural Hospitals in Achieving Equitable Surgical Access in Low-Resourced Settings

 

Author list: Kathryn Chu, Rebecca Maine & Riaan Duvenage

 

 

Abstract:

Strengthening and defining the role of rural hospitals within a surgical ecosystem is essential to improving quality and timely surgical access for rural people in low and middle-income countries (LMICs). Regional hospitals are the cornerstone of LMIC rural surgical care but have insufficient human resources and infrastructure that limit the surgical care they can provide. District hospitals are most accessible for many rural patients but also have limited surgical capacity. In order to surgical access for rural people, both regional and district hospital surgical services must be strengthened. A strong relationship between regional and district hospitals through a hub and spoke model is needed. Regional hospital surgeons can support training and supervision for and referrals from district hospitals. Telemedicine can play a key role to leapfrog physical barriers and surgical specialist shortages. The changing demographics of surgical disease will continue to worsen the strain on tertiary hospitals where most subspecialists in LMICs work. The fewer rural patients who need to travel to urban referral and tertiary facilities for problems that can be managed at lower-level facilities, the better access to timely surgical care for all.


Free Link: https://rdcu.be/cxGzN

 

 


My First Paper: The Optimal Definition of Sarcopenia for Predicting Postoperative Pneumonia after Esophagectomy in Patients with Esophageal Cancer

 

 

Author list: Mikio Nambara, Yuichiro Miki, Tatsuro Tamura, Mami Yoshii, Takahiro Toyokawa, Hiroaki Tanaka, Shigeru Lee, Kazuya Muguruma, Toshihiko Shibata & Masaichi Ohira

 

Abstract:

Background

Esophageal cancer (EC) is associated with malnutrition in the vast majority of patients, and this often leads to sarcopenia, which is characterised by loss of skeletal muscle mass (SMM). Although sarcopenia could be one of the risk factors for postoperative pneumonia (PP), the optimal definition of sarcopenia using skeletal muscle mass index (SMI) by bioelectrical impedance analysis (BIA) remains unknown for predicting PP after esophagectomy in patients with EC. Therefore, this study aimed to identify high-risk patients for PP after esophagectomy through evaluating SMI by BIA and set an appropriate cut-off value for this purpose.

 

Method

A total of 73 patients with EC who underwent subtotal esophagectomy with lymph node dissection at Osaka City University Hospital between 2017 and 2019 were reviewed retrospectively. The association between PP and perioperative factors including SMI by BIA were analysed. When SMI was lower than the cut-off values proposed by two study groups (Asian Working Group for Sarcopenia (AWGS) and original European Working Group on Sarcopenia in Older People (EWGSOP)) or SMM was less than 90% of standard, the patient was diagnosed with sarcopenia. Receiver operating characteristic analysis was performed to set the appropriate cut-off value of SMI, and a new criterion (modified EWGSOP) was formulated by using the value. Clinicopathological factors and postoperative complications between sarcopenia and non-sarcopenia groups were compared, which were classified by four different criteria: (1) AWGS, (2) original EWGSOP, (3) < 90% standard and (4) modified EWGSOP criteria.

 

Results

Nine patients (12.3%) were with PP grade III or higher. Total SMI as well as body mass index (BMI), transthyretin and % vital capacity (%VC) were found to be significantly associated with PP (Clavien–Dindo grade ≥ III).

 

BMI, total and appendicular SMI of sarcopenic patients were found to be lower than those of non-sarcopenic patients. Low serum albumin and %VC were significantly associated with sarcopenia defined by modified EWGSOP criteria. The rate of PP was significantly higher in sarcopenic patients when the original and modified EWGSOP criteria were used (p = 0.0079 and 0.0015, respectively).

 

A multivariate analysis revealed that sarcopenic state by modified EWGSOP criteria was the significant independent predictive factor of PP [p = 0.0031, hazard ratio (HR) = 10.1; 95% confidential interval (CI): 2.12–76.9].

 

Conclusion

Preoperative sarcopenia by modified EWGSOP criteria could be the best indicator using BIA for predicting PP after esophagectomy in patients with EC.


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My First Paper: Surgical Resection of Tumors Invading the Inferior Vena Cava at the Hepatic Vein and Thoracic Levels

Author list: Justin Issard, Antonio Sa Cunha, Dominique Fabre, Delphine Mitilian, Sacha Mussot, Olaf Mercier, David Boulate & Elie Fadel

 

Abstract:

Background

Our aim was to describe the results of our program of surgical resection of tumors invading the inferior vena cava (IVC) at the hepatic and thoracic levels. We hypothesized that similar surgical outcomes may be obtained compared to tumor resection below the hepatic vein level if the liver function was preserved.

 

Methods

We performed a single-center retrospective study of 72 consecutive patients who underwent surgical resection from 1996 to 2019 for tumors invading the IVC. We compared two groups based on tumor location below (group I/II) or above (group III/IV) the inferior limit of hepatic veins.

 

Results

Tumor histology was similarly distributed between groups. In group III/IV (n = 35), sterno-laparotomy was used in 83% of patients, cardiopulmonary bypass in 77%, and deep hypothermic circulatory arrest in 17%; 23% underwent liver resection. Corresponding proportions in group I/II were 3%, 0%, 0%, and 8%. In group III/IV, 4 patients required emergency resection. Mortality on day 30 was 17% (n = 6) in group III/IV and 0% in group I/II (P = 0.01). There was no liver failure among the 66 postoperative survivors and 5 out of 6 patients who died postoperatively presented a preoperative or postoperative liver failure (P < 0.001). Overall survival was not significantly different between groups with a median follow-up of 15.1 months. R0 resection was achieved in 66% of group I/II and 49% of group III/IV patients (P = 0.03).

 

Conclusion

Surgical resection of tumors invading the inferior vena cava at hepatic vein and thoracic levels should be reserved to carefully selected patients without preoperative liver failure to minimize postoperative mortality.


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The Impact of Quality Improvement Interventions in Improving Surgical Infections and Mortality in Low and Middle-Income Countries

Author list: James Jin, Salesi ′Akau′ola, Cheng-Har Yip, Peter Nthumba, Emmanuel A. Ameh, Stijn de Jonge, Mira Mehes, Hon. Iferemi Waiqanabete, Jaymie Henry, Andrew Hill on behalf of The International Society of Surgery (ISS) and the G4 Alliance International Standards and Guidelines for Quality Safe Surgery and Anesthesia (ISG-QSSA) Group

 

Abstract:

Background

Morbidity and mortality in surgical systems in low- and middle-income countries (LMICs) remain high compared to high-income countries. Quality improvement processes, interventions, and structure are essential in the effort to improve peri-operative outcomes.

 

Methods

A systematic review and meta-analysis of interventional studies assessing quality improvement processes, interventions, and structure in developing country surgical systems was conducted according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were included if they were conducted in an LMIC, occurred in a surgical setting, and measured the effect of an implementation and its impact. The primary outcome was mortality, and secondary outcomes were rates of rates of hospital-acquired infection (HAI) and surgical site infections (SSI). Prospero Registration: CRD42020171542.

 

Result

Of 38,273 search results, 31 studies were included in a qualitative synthesis, and 28 articles were included in a meta-analysis. Implementation of multimodal bundled interventions reduced the incidence of HAI by a relative risk (RR) of 0.39 (95%CI 0.26 to 0.59), the effect of hand hygiene interventions on HAIs showed a non-significant effect of RR of 0.69 (0.46–1.05). The WHO Safe Surgery Checklist reduced mortality by RR 0.68 (0.49 to 0.95) and SSI by RR 0.50 (0.33 to 0.63) and antimicrobial stewardship interventions reduced SSI by RR 0.67 (0.48–0.93).

 

Conclusion

There is evidence that a number of quality improvement processes, interventions and structural changes can improve mortality, HAI and SSI outcomes in the peri-operative setting in LMICs.

 


Free Link: https://rdcu.be/cxGBr


Postoperative Pain Relief after Pancreatic Resection

Author list: Nasreen Akter, Bathiya Ratnayake, Daniel B. Joh, Sara-Jane Chan, Emily Bonner & Sanjay Pandanaboyana

 

Abstract:

Background

This systematic review explored the efficacy of different pain relief modalities used in the management of postoperative pain following pancreatoduodenectomy (PD) and distal pancreatectomy (DP) and impact on perioperative outcomes.

 

Methods

MEDLINE (OVID), Embase, Pubmed, Web of Science and CENTRAL databases were searched using PRISMA framework. Primary outcomes included pain on postoperative day 2 and 4 and respiratory morbidity. Secondary outcomes included operation time, bile leak, delayed gastric emptying, postoperative pancreatic fistula, length of stay, and opioid use.

 

Results

Five randomized controlled trials and seven retrospective cohort studies (1313 patients) were included in the systematic review. Studies compared epidural analgesia (EDA) (n = 845), patient controlled analgesia (PCA) (n = 425) and transabdominal wound catheters (TAWC) (n = 43). EDA versus PCA following PD was compared in eight studies (1004 patients) in the quantitative meta-analysis. Pain scores on day 2 (p = 0.19) and 4 (p = 0.18) and respiratory morbidity (p = 0.42) were comparable between EDA and PCA. Operative times, bile leak, delayed gastric emptying, pancreatic fistula, opioid use, and length of stay also were comparable between EDA and PCA. Pain scores and perioperative outcomes were comparable between EDA and PCA following DP and EDA and TAWC following PD.

 

Conclusions

EDA, PCA and TAWC are the most frequently used analgesic modalities in pancreatic surgery. Pain relief and other perioperative outcomes are comparable between them. Further larger randomized controlled trials are warranted to explore the relative merits of each analgesic modality on postoperative outcomes with emphasis on postoperative complications.

 

 


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