Featured Articles in Sep 2018

World Journal of Surgery Becomes the Official Publication of the ERAS Society

 

Author list: Julie Ann Sosa, Olle Ljungqvist

 

Abstract:

It is with great excitement that we announce that the World Journal of Surgery has become the official journal for the Enhanced Recovery After Surgery (ERAS) Society. WJS continues to be the official journal of the International Society of Surgery (ISS). This new relationship with ERAS very much fits the mission of WJS, which is to promote innovation and discovery that helps to improve patient outcomes on the international stage.

 

URL: https://rdcu.be/3KnP

 

 


Respiratory Complications After Colorectal Surgery: Avoidable or Fate?

 

Author list: Jonas Jurt, Martin Hubner, Basile Pache, Dieter Hahnloser, Nicolas Demartines, Fabian Grass

 

Abstract:

Background

The prevention of post-operative pulmonary complications (PPC) is targeted by several enhanced recovery (ERAS) items including early mobilisation, prevention of fluid overload and omission of routine nasogastric tubes. The aim of the present study was to assess the impact of ERAS on PPC.

 

Methods

ERAS procedures from May 2011 until May 2017. Multiple logistic regressions were performed to identify risk factors for PPC among demographic, surgical characteristics and items related to the ERAS protocol.

 

Results

In total, 1298 patients were included; among them 120 (9.2%) had one or more PPC. Multivariable analysis retained minimally invasive surgery [odds ratio (OR) 0.26; 95% confidence interval (CI) 0.15–0.46] and compliance to the ERAS protocol of ≥ 70% (OR 0.53; CI 0.30–0.94) as protective factors. Emergency surgery (OR 2.70; CI 1.20–6.01), blood loss of ≥ 200 mL (OR 2.06; CI 1.20–3.53) and ASA score of ≥ 3 (OR 2.00; CI 1.12–3.57) were independent risk factors. Median length of hospital stay was significantly longer in patients who experienced respiratory complications (21 [4–183] vs. 6 [1–95] days, p ≤ 0.001).

 

Conclusion

Minimally invasive surgery and high compliance with the ERAS protocol can help to prevent PPC.

 

URL: https://rdcu.be/3KkI

 


Incorporation of a Global Surgery Rotation into an Academic General Surgery Residency Program: Impact and Perceptions

 

Author list: Michael Thomas LeCompte, Connor Goldman, John L. Tarpley, Margaret Tarpley, Erik N. Hansen, Peter M. Nthumba, Kyla P. Terhune, Rondi M. Kauffmann

 

Abstract:

Background

Global surgery is increasingly recognized as a vital component of international public health. Access to basic surgical care is limited in much of the world, resulting in a global burden of treatable disease. To address the lack of surgical workforce in underserved environments and to foster ongoing interest in global health among US-trained surgeons, our institution established a residency rotation through partnership with an academic hospital in Kijabe, Kenya. This study evaluates the perceptions of residents involved in the rotation, as well as its impact on their future involvement in global health.

 

Methods

A retrospective review of admission applications from residents matriculating at our institution was conducted to determine stated interest in global surgery. These were compared to post-rotation evaluations and follow-up surveys to assess interest in global surgery and the effects of the rotation on the practices of the participants.

 

Results

A total of 78 residents matriculated from 2006 to 2016. Seventeen participated in the rotation with 76% of these reporting high satisfaction with the rotation. Sixty-five percent had no prior experience providing health care in an international setting. Post-rotation surveys revealed an increase in global surgery interest among participants. Long-term interest was demonstrated in 33% (n = 6) who reported ongoing activity in global health in their current practices. Participation in global rotations was also associated with increased interest in domestically underserved populations and affected economic and cost decisions within graduates’ practices.

 

URL: https://rdcu.be/3Kk5

 


Primary Hyperparathyroidism is Underdiagnosed and Suboptimally Treated in the Clinical Setting

 

Author list: Jacob Enell, Haytham Bayadsi, Ewa Lundgren, Joakim Hennings

 

Abstract:

Background

To evaluate whether patients presenting with laboratory results consistent with primary hyperparathyroidism (pHPT) are managed in accordance with guidelines.

 

Methods

The laboratory database at a hospital in Sweden, serving 127,000 inhabitants, was searched for patients with biochemically determined pHPT. During 2014, a total of 365 patients with biochemical laboratory tests consistent with pHPT were identified. Patients with possible differential diagnoses or other reasons for not being investigated according to international guidelines were excluded after scrutinizing records, after new blood tests, and clinical assessments by endocrine surgeons.

 

Results

Altogether, 92 patients had been referred to specialists and 82 had not. The latter group had lower serum calcium (median 2.54 mmol/L) and PTH (5.7 pmol/L). Out of these 82 cases, 9 patients were diagnosed with pHPT or had some sort of long-term follow-up planned as outpatients.

 

Conclusion

Primary hyperparathyroidism is overlooked and underdiagnosed in a number of patients in the clinical setting. It is important to provide local guidelines for the management of patients presenting with mild pHPT to ensure that these patients receive proper evaluation and follow-up according to current research.

 

URL: https://rdcu.be/3Klq

 


Preoperative Smoking Cessation is Integral to the Prevention of Postoperative Morbidities in Minimally Invasive Esophagectomy

 

Author list: 

Naoya Yoshida, Kenichi Nakamura, Daisuke Kuroda, Yoshifumi Baba, Yuji Miyamoto, Masaaki Iwatsuki, Yukiharu Hiyoshi, Takatsugu Ishimoto, Yu Imamura, Masayuki Watanabe, Hideo Baba

 

Abstract:

Background

Preoperative smoking cessation is considered integral to decreasing postoperative morbidities after esophagectomy. To our knowledge, the association of the duration of smoking cessation with the occurrence of postoperative morbidity has never been investigated in minimally invasive esophagectomy (MIE).

 

Methods

A total of 198 consecutive MIEs for esophageal cancer between June 2011 and December 2017 were eligible for the study. According to the length of smoking cessation, patients were separated into three groups: ≤ 30, 31–90, and ≥ 91 days. Incidence of postoperative morbidities was retrospectively analyzed among the groups.

 

Results

In patients with smoking cessation ≤ 30 days, morbidities of Clavien–Dindo classification (CDc) ≥ II, severe morbidities of CDc ≥ IIIb, pneumonia, and any pulmonary morbidities were frequently observed. Morbidities of CDc ≥ II, pneumonia, and any pulmonary morbidities increased as the length of cessation became shorter. Smoking cessation ≤ 30 days was a significant risk factor for severe morbidity (hazard ratio [HR] 4.89, 95% confidence interval [CI] 1.993–12.011; P < 0.001). Smoking cessation ≤ 90 days (HR 3.98, 95% CI 1.442–10.971; P = 0.008), past smoking (per 100 increase in Brinkman index), and cardiovascular comorbidity were significant risk factors for pneumonia. Smoking cessation ≤ 30 days (HR 3.13, 95% CI 1.351–7.252; P = 0.008) and past smoking were significant risk factors for any pulmonary morbidity.

 

Conclusion

Preoperative smoking cessation is considerably important to prevent postoperative morbidities, even in MIE. At least, preoperative cessation ≥ 31 days is preferable to decrease considerable morbidities after MIE.

 

URL: https://rdcu.be/3KlR

 


Chemoradiotherapy for Initially Unresectable Locally Advanced Cholangiocarcinoma

 

Author list: Tatsuaki Sumiyoshi, Yasuo Shima, Takehiro Okabayashi, Yuji Negoro, Yasuhiro Shimada, Manabu Matsumoto, Yasuhiro Hata, Yoshihiro Noda, Kenta Sui, Taijiro Sueda

 

Abstract:

Background

Surgical resection is the only available treatment for achieving long-term survival in cholangiocarcinoma. The purpose of this study is to elucidate the utility of chemoradiotherapy for initially unresectable locally advanced cholangiocarcinoma.

 

Methods

Unresectable locally advanced cholangiocarcinoma was defined as those in which radical surgery could not be achieved even with aggressive surgical procedure. Fifteen candidates (7 intrahepatic cholangiocarcinomas and 8 hilar cholangiocarcinomas) underwent chemoradiotherapy. Fourteen of the 15 patients received oral S-1 chemotherapy. Radiotherapy was administered with 50 Gy for each patient. After chemoradiotherapy, the resectability of each cholangiocarcinoma was reexamined.

 

Results

Of the 15 patients with initially unresectable locally advanced cholangiocarcinoma, 11 (73.3%) were judged to have resectable cholangiocarcinoma after chemoradiotherapy, and received radical hepatectomy (R0 resection in 9 patients). Among the 11 patients who underwent surgical resection, 4 had recurrence-free survival and the median survival time (MST) was 37 months. The overall 1-, 2-, and 5-year survival rates were 80.8, 70.7 and 23.6%, respectively. Among the 4 patients who were unable to receive surgery, 3 died of the primary disease and the MST was 10 months. The overall 1- and 2-year survival rates were 37.5 and 0%, respectively. Patients who received radical surgery had significantly longer survival time than those who were unable to receive surgery (p = 0.027).

 

Conclusions

Chemoradiotherapy allowed patients with initially unresectable locally advanced cholangiocarcinomas to be reclassified as surgical candidates in a substantial proportion. Chemoradiotherapy might be one of the treatment options for similarly advanced cholangiocarcinomas.

 

URL: https://rdcu.be/3Kmi

 


The Impact of Total Body Prehabilitation on Post-Operative Outcomes After Major Abdominal Surgery: A Systematic Review

 

Author list: Alison Luther, Joseph Gabriel, Richard P. Watson, Nader K. Francis

 

Abstract:

Background

Despite advances in perioperative care, post-operative clinical and functional outcomes after major abdominal surgery can be suboptimal. Prehabilitation programmes attempt to optimise a patient’s preoperative condition to improve outcomes. Total body prehabilitation includes structured exercise, nutritional optimisation, psychological support and cessation of negative health behaviours. This systematic review aims to report on the current literature regarding the impact of total body prehabilitation prior to major abdominal surgery.

 

Methods

Relevant studies published between January 2000 and July 2017 were identified using MEDLINE, EMBASE, AMED, CINAHL, PsychINFO, PubMed, and the Cochrane Database. All studies published in a peer-reviewed journal, assessing post-operative clinical and functional outcomes, following a prehabilitation programme prior to major abdominal surgery were included. Studies with less than ten patients, or a prehabilitation programme lasting less than 7 days were excluded.

 

Results

Sixteen studies were included, incorporating 2591 patients, with 1255 undergoing a prehabilitation programme. The studies were very heterogeneous, with multiple surgical sub-specialties, prehabilitation techniques, and outcomes assessed. Post-operative complication rate was reduced in six gastrointestinal studies utilising either preoperative exercise, nutritional supplementation in malnourished patients or smoking cessation. Improved functional outcomes were observed following a multimodal prehabilitation programme. Compliance was variably measured across the studies (range 16–100%).

 

Conclusions

There is substantial heterogeneity in the prehabilitation programmes used prior to major abdominal surgery. A multimodal approach is likely to have better impact on functional outcomes compared to single modality; however, there is insufficient data either to identify the optimum programme, or to recommend routine clinical implementation.

 

URL: https://rdcu.be/3KmF

 


Systematic Review and Meta-analysis of Restrictive Perioperative Fluid Management in Pancreaticoduodenectomy

 

 

 

Author list: Brian P. Chen, Marian Chen, Sean Bennett, Kristina Lemon, Kimberly A. Bertens, Fasy K. Balaa, Guillaume Martel

 

Abstract:

Background

There is significant interest and controversy surrounding the effect of restrictive fluid management on outcomes in major gastrointestinal surgery. This has been most studied in colorectal surgery, although the literature relating to pancreaticoduodenectomy (PD) patients is growing. The aim of this paper was to generate a comprehensive review of the available evidence for restrictive perioperative fluid management strategies and outcomes in PD.

 

Methods

MEDLINE/PubMed, Embase, and the Cochrane Library were searched from inception to April 2017. A review protocol was utilized and registered with PROSPERO. Primary citations that evaluated perioperative fluid management in PD, including those as part of a clinical pathway, were considered. The primary outcome was postoperative pancreatic fistula (POPF). Secondary outcomes included delayed gastric emptying (DGE), complication rate, length of stay (LOS), mortality, and readmission.

 

Results

A total of six studies involving 846 patients were included (2009–2015), of which four were RCTs. Pooled analysis of RCTs and high-quality observational studies found no effect of restrictive intraoperative fluid management on POPF, DGE, complication rate, LOS, mortality, and readmission. Only one study assessed postoperative fluid management exclusively and found prolonged LOS in patients in the restricted fluid group.

 

Conclusions

Based on results of RCTs and high-quality observational studies, intraoperative fluid restriction in PD has not been shown to significantly affect postoperative outcomes. There are too few studies assessing postoperative fluid management to draw conclusions at this time.

 

URL: https://rdcu.be/3Km6


Prognostic Impact of Bacterobilia on Morbidity and Postoperative Management After Pancreatoduodenectomy: A Systematic Review and Meta-analysis

Author list: Benjamin Mussle, Sebastian Hempel, Christoph Kahlert, Marius Distler, Jurgen Weitz, Thilo Welsch

 

Abstract:

Background

Intraoperative bile analysis during pancreatoduodenectomy (PD) is performed routinely at specialized centers worldwide. However, it remains controversial if and how intraoperative bacterobilia during PD affects morbidity and its management. The aim of the study was a systematic review and meta-analysis of intraoperative bacterobilia and its impact on patient outcome after PD.

 

Methods

Five relevant outcomes of interest were defined, and a systematic review of the literature with meta-analysis was performed according to the PRISMA guidelines.

 

Results

A total of 28 studies (8523 patients) were included. The median incidence of bacterobilia was 58% (interquartile range 51–67%). The most frequently isolated bacteria were Enterococcus species (51%), Klebsiella species (28%), and Escherichia coli (27%). Preoperative biliary drainage was significantly associated with bacterobilia (86 vs. 25%; RR 3.27; 95% confidence interval (CI) 2.42–4.42; p < 0.001). The incidence of surgical site infections (SSI) was significantly increased in cases with bacterobilia (RR 2.84; 95% CI 2.17–3.73; p < 0.001). Postoperative pancreatic fistula, overall postoperative morbidity, and mortality were not significantly influenced. Identical bacteria in bile and the infectious sources were found in 48% (interquartile range 34–59%) of the cases.

 

Conclusions

Bacterobilia is detected during almost every second PD and is associated with an increased rate of SSI. The microbiome from intraoperative bile and postoperative infectious sources match in ~50% of patients, providing the option of early administration of calculated antibiotics and the determination of resistance patterns.

 

URL: https://rdcu.be/3Knl


Laparoscopic Versus Open Transverse Colectomy: A Systematic Review and Meta-Analysis

 

 

Author list: Paschalis Gavriilidis, Konstantinos Katsanos

 

Abstract:

Background

The survival benefits, oncological adequacy, effectiveness, and safety of laparoscopic transverse colectomy (LTC) were compared with that of open transverse colectomy (OTC) using a meta-analysis.

 

Methods

EMBASE, Medline, Cochrane library, and Google scholar databases were searched for the last 20 years. Meta-analyses were performed using both fixed-effects and random-effects models. Five-year disease-free survival and overall survival were estimated using the inverse variance hazard ratio method.

 

Results

No survival benefits were detected between the two LTC and OTC cohorts. OTC showed shorter operative time by 38 min compared to LTC [mean difference (MD) = 38(15.23–60.77), p = 0.001]. However, LTC was associated with earlier postoperative recovery. The time to flatus and time to oral intake for LTC were MD = −1.12(−1.68 to −0.55, p = 0.001) and MD = −1.57(−2.38 to −0.76, p = 0.001), respectively. In addition, LTC was associated with a shorter hospital stay by 4.5 days [MD = −4.64(−7.52 to −1.75), p = 0.002].

 

Conclusions

Compared to OTC, LTC provides similar survival benefits, earlier postoperative recovery, and shorter hospital stay by 4.5 days.

 

URL: https://rdcu.be/3KnD

 

 

 

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