Featured Articles in Dec 2017

Advancing Global Surgery: Moving Beyond Identifying Problems to Finding Solutions

 

Author list: Anthony G. Charles, Charles Mock

 

Abstract:

Over the past two decades, global surgery has evolved into a well-recognized surgical discipline. This has come about for several reasons beyond the moral imperative. With the emphasis in global health shifting from communicable to non-communicable diseases, global surgery is now uniquely positioned to expand and take its rightful place within global public health. Historically, the emphasis among global surgery researchers, in order to gain a seat at the public health table, was to capture and describe the enormity of the global burden of surgical diseases as it relates to mortality. This has led to the plethora of publications on surgical epidemiology, characteristics and outcomes in differing geographic locations, particularly in low- and middle-income countries, and all have a uniform theme—poor access to surgical care, and high surgical burden of diseases resulting in increased mortality and disability. Unfortunately, countries with the highest surgical burden of disease are typically those with the lowest gross domestic product, worst infrastructure, and areas in active or recent conflict with associated poor health-care systems and weak governance.

 

In this collection of articles, we highlight research across the world that proffers innovative solutions to the well-described issues in global surgery. The articles in this collection cover a spectrum of topics ranging from specific techniques in the operating room to national policy. These include: details of operative care (fracture care in Cambodia) [1], hospital-wide programs to improve trauma care in Malawi [2], quality improvement (safe surgery checklist in Cambodia) [3], innovative measures to improve access to surgery through use of patient navigators in Haiti [4] and a nationwide surgical plan in Ethiopia [5].

 

URL: http://rdcu.be/xV0B

 


Cost-Effectiveness of a Locally Organized Surgical Outreach Mission: Making a Case for Strengthening Local Non-Governmental Organizations

 

Author list: Adam Gyedu, Cameron Gaskill, Godfred Boakye, Francis Abantanga

 

Abstract:

Background

Many low- and middle-income countries (LMICs) have a high prevalence of unmet surgical need. Provision of operations through surgical outreach missions, mostly led by foreign organizations, offers a way to address the problem. We sought to assess the cost-effectiveness of surgical outreach missions provided by a wholly local organization in Ghana to highlight the role local groups might play in reducing the unmet surgical need of their communities.

 

Methods

We calculated the disability-adjusted life years (DALY) averted by surgical outreach mission activities of ApriDec Medical Outreach Group (AMOG), a Ghanaian non-governmental organization. The total cost of their activities was also calculated. Conclusions about cost-effectiveness were made according to World Health Organization (WHO)-suggested parameters.

 

Results

We analyzed 2008 patients who had been operated upon by AMOG since December 2011. Operations performed included hernia repairs (824 patients, 41%) and excision biopsy of soft tissue masses (364 patients, 18%). More specialized operations included thyroidectomy (103 patients, 5.1%), urological procedures (including prostatectomy) (71 patients, 3.5%), and plastic surgery (26 patients, 1.3%). Total cost of the outreach trips was $283,762, and 2079 DALY were averted; cost per DALY averted was 136.49 USD. The mission trips were “very cost-effective” per WHO parameters. There was a trend toward a lower cost per DALY averted with subsequent outreach trips organized by AMOG.

 

Conclusion

Our findings suggest that providing surgical services through wholly local surgical mission trips to underserved LMIC communities might represent a cost-effective and viable option for countries seeking to reduce the growing unmet surgical needs of their populations.

 

URL: http://rdcu.be/xV1z


A Description of Deaths Following Emergency Abdominal Surgery

 

Author list: Henrik Wolsted, Ann Merete Moller, Mai-Britt Tolstrup, Morten Vester-Andersen

 

Abstract:

Background

Emergency major abdominal surgery carries a high mortality rate. The aim of this present study was to characterize a population of deceased abdominal surgical patients, to examine how many died unexpectedly and how many were subject to treatment limitations.

 

Methods

We included adult emergency abdominal surgical patients who died within 30 days postoperatively. We collected data from January 1, 2013, to December 31, 2014, in a Danish tertiary care hospital (Herlev).

 

Results

A total of 138 patients were included which corresponded to a crude mortality rate of 16.5% in the population. Four percent (5 of 138) of the patients died unexpectedly without any prior signs of deterioration and 46% (65 of 138) experienced a complicated treatment course, 67% of which was treated in the intensive care unit (ICU). The remaining 50% (68 of 138) had treatment limitations, applied pre- or postoperatively, of which 4% were treated in the ICU ward.

 

Conclusion

In the present study, we found a high number of patients with treatment limitations, offering one explanation to why so relatively few high-risk surgical patients are admitted to the ICU ward. Whether intermediary wards could serve as a viable alternative for these patients, securing a sufficient level of treatment without taking up scarce beds in the intensive care unit, remains an important question for future studies. Furthermore, five patients died unexpectedly, without any clear cause of death, proving that continual strides toward improving the overall process of postoperative care are still demanded.

 

URL: http://rdcu.be/xV2b


High Expression of Angiopoietin-1 is Associated with Lymph Node Metastasis and Invasiveness of Papillary Thyroid Carcinoma

 

Author list: Yea Eun Kang, Koon Soon Kim, Sung Jae Park, Seung-Nam Jung, Jae Won Chang, Shinae Yi, Min Gyu Jung, Jin-man Kim, Bon Seok Koo

 

Abstract:

Background

We investigated the expression of angiopoietins in patients with papillary thyroid carcinoma (PTC) and the role of angiopoietins as biomarkers predicting the aggressiveness of PTC.

Methods

Expression of angiopoietins was evaluated by immunohistochemistry of tumor specimens from patients with PTC. We demonstrated potential correlations between expression of angiopoietins and clinicopathologic features.

 

Results

High expression of Ang-1 was positively correlated with a tumor size >1 cm, capsular invasion, extrathyroid extension, lymphovascular invasion, lymph node metastasis, and recurrence (P < 0.05). Moreover, multivariate analysis revealed that high expression of Ang-1 was an independent risk factor for lymph node metastasis (P < 0.001, odds ratio [OR] = 62.113) and lymphovascular invasion (P = 0.027, OR 4.405). However, there was no significant correlation between Ang-2 and clinicopathologic features.

 

Conclusions

Our results suggest that Ang-1 can serve as a valuable prognostic biomarker for lymph node metastasis and invasiveness in patients with PTC.

 

URL: http://rdcu.be/xV2F


Laparoscopic Compared to Open Repeat Hepatectomy for Colorectal Liver Metastases: a Multi-institutional Propensity-Matched Analysis of Short- and Long-Term Outcomes

 

Author list: Julie Hallet, Antonio Sa Cunha, Daniel Cherqui, Brice Gayat, Diane Goere, Philippe Bachellier, Alexis Laurent, David Fuks, Francis Navarro, Patrick Pessaux

 

Abstract:

Background

While uptake of laparoscopic hepatectomy has improved, evidence on laparoscopic re-hepatectomy (LRH) for colorectal liver metastases (CRLMs) is limited and has never been compared to the open approach. We sought to define outcomes of LRH compared to open re-hepatectomy (ORH).

 

Methods

Patients undergoing re-hepatectomy for CRLM at 39 institutions (2006–2013) were identified. Primary outcomes were 30-day post-operative overall morbidity, mortality, and length of stay. Secondary outcomes were recurrence and survival at latest follow-up. LRHs were matched to ORHs (1:3) using a propensity score created by comparing pre-operative clinicopathologic factors (number and size of liver metastases and major hepatectomy).

 

Results

Of 376 re-hepatectomies included, 27 were LRH, including 1 (3.7%) conversion. The propensity-matched cohort included 108 patients. Neither median operative time (252 vs. 230 min; p = 0.82) nor overall 30-day morbidity (48.1 vs. 38.3%; p = 0.37) differed. Non-specific morbidity (including cardiac, respiratory, infectious, and renal events) decreased with LRH (11.1 vs. 30.9%, p = 0.04), while surgical-specific morbidity, including liver insufficiency, was higher (44.4 vs. 22.2%, p = 0.03). One ORH and 0 LRH suffered 30-day mortality. Median length of stay (9 vs. 12 days; p = 0.60) was comparable. At latest follow-up, 26 (96.3%) LRH and 67 (82.7%) ORH patients were alive. Eight (29.6%) LRH and 36 (44.4%) ORH patients were alive without disease.

 

Conclusions

LRH for recurrent CRLM was associated with overall short-term outcomes comparable to ORH, but different morbidity profiles. While it may offer a safe and feasible approach, further insight is necessary to better define patient selection.

 

URL: http://rdcu.be/xV25


Laparoscopic Treatment in Children with Hydatid Cyst of the Liver

 

Author list: Sergey V. Minaev, Igor N. Gerasimenko, Igor V. Kirgizov, Azamat M. Shamsiev, Nikolay I. Bykov, Jamshid A. Shamsiev, Alina N. Maschenko

 

Abstract:

Background

There is no consensus on the surgical treatment of children with hydatid cyst of the liver (HCL). We evaluated the outcomes of laparoscopic and open surgery for childhood HCL.

 

Methods

We performed 81 open surgery and laparoscopic procedures in 37 (45.7%) boys and 44 (54.3%) girls with HCL (mean age 9.3 ± 2.1 years) who were assigned to a main group (laparoscopy, n = 21) and a control group (open surgery, n = 60). Clinical assessments, surgical durations, complications, and postoperative outcomes were investigated. Cyst types in the two groups were I (Gharbi)/CE 1 (WHO-IWGE), 71.4 and 58.3%, respectively; II/CE 2, 19.1 and 25.0%, respectively; and III/CE 3, 9.5 and 16.7%, respectively. The parasitic hydatid cysts were located mostly in the right liver lobe in both the main and control groups (90.4 and 80.0%, respectively).

 

Results

Hospital stays were significantly (p < 0.05) longer in patients in the control group (12.1 ± 1.5 vs. 5.6 ± 2.2 days). Operation time was significantly (p < 0.01) shorter for the main group (90.1 ± 7.8 vs. 120.6 ± 5.3 min). Local complications (residual cavity infection, biliary fistula) occurred in 21.6% of patients in the control group and 14.3% in the main group. Each was treated, and none recurred. There were no apparent systemic complications.

 

Conclusions

Laparoscopic surgical treatment for children with HCL is safe in compliance with all classic open surgery principles. The laparoscopic technique offered a shorter duration of the surgical effects and markedly fewer postoperative complications.

 

URL: http://rdcu.be/xV3A


Systematic Review and Meta-Analysis of Laparoscopic Versus Open Appendicectomy in Adults with Complicated Appendicitis: an Update of the Literature

 

Author list: Christos Athanasiou, Sonia Lockwood, Georgios A. Markides

 

Abstract:

Background

To review and compare the outcomes of laparoscopic (LA) versus open appendicectomy (OA) in complicated appendicitis in adult patients, eight years after the last literature review.

 

Methods

The PRISMA guidelines were adhered to. Pre-defined inclusion and exclusion criteria were used to search the PubMed, Scopus and Cochrane databases and extract relevant data. Methodological and quality assessment was undertaken with outcome meta-analysis and subgroup analyses of methodological quality, type of study and year of study. Assessment of clinical and statistical heterogeneity and publication bias was conducted.

 

Results

Three randomised control trials (RCTs) (154LA vs 155OA) and 23 case–control trials were included (2034LA vs 2096OA). Methodological quality was low to average but with low statistical heterogeneity. Risk of publication bias was low, and meta-regression indicated shorter length of hospital stay (LOS) in more recent studies, Q = 7.1, P = 0.007. In the combined analysis LA had significantly less surgical site infections [OR = 0.30 (0.22,0.40); p < 0.00001] with reduced time to oral intake [WMD = -0.98 (-1.09,-0.86); P < 0.00001] and LOS [WMD = -3.49(-3.70,-3.29); p < 0.00001]. There was no significant difference in intra-abdominal abscess rates [OR = 1.11(0.85,1.45); p = 0.43]. Operative time was longer during LA [WMD = 10.51 (5.14,15.87); p = 0.0001] but did not reach statistical significance (p = 0.13) in the RCT subgroup analysis.

 

Conclusions

LA appears to have significant benefits with improved morbidity compared to OA in complicated appendicitis (level of evidence II).

 

URL: http://rdcu.be/xV6X


 

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