Surgery in practice and science最新文献

Introduction

Case-based learning (CBL) utilizes authentic clinical cases that connect theory to practice. CBL has been shown to result in deeper learning and high engagement of adult learners. An open-source, web-based CBL module was created to help learners develop the cognitive foundation of ectopic pregnancy management in the low-resource setting. We present psychometric evidence that supports the use of this web-based CBL in the low-resource setting.

Methods

The case scenario comprising 20 topics in ectopic pregnancy management was created by an Ethiopian team member and hosted on an interactive web-based platform. The module was reviewed by Ethiopian, Cameroonian, and US surgeons and OB/GYN team members for content, relevance, and clarity, followed by a psychometrician for clarity, bias, relevance, and alignment. Twenty participants (3-Mbingo Baptist Hospital-Cameroon, 6-Soddo Christian Hospital-Ethiopia, 3-Southern Illinois University (SIU), and 8-University of Michigan (UM)) then completed the module. Four attending surgeons (2 OB/GYN, 2 general surgery) were designated experts while 10 medical students and 6 residents were designated novices. The module included a 10-item dichotomously scored pre-test, the CBL content, and the same, but shuffled, post-test. Pre- and post-test summed scores were compared using paired Student's t-tests, while differences in scores across participants' experience levels and sites were analyzed using a many-facet Rasch model.

Results

Findings indicated a statistically significant improvement in participants’ mean summed scores from pre-test (M = 6.7, SD = 2.2) to post-test (M = 9.0, SD = 1.5), t(20) = – 4.76, P < 0.0001 and confirmed by Rasch analysis, P < 0.001. An adequate distribution of difficulty was demonstrated and 80% of questions had high discrimination value between experts and novices, d = | 0.87, 1.40 |. There was no difference in scores across specialties. Following the module, expert scores (M = 9.7) were higher than novice scores (M = 9.0), but the difference was not statistically significant.

Conclusion

Our findings suggest that using a web-based CBL module could be used to effectively improve understanding of the management of ectopic pregnancy in the low-resource setting, especially for nascent surgeons. The concept of a web-based CBL module has special attraction in the low-resource setting as it may target the adult surgical learner in remote regions where established technologies and existing experts are unavailable.

Introduction

Gallstone ileus is an uncommon etiology of intestinal obstruction, although many cases require surgical repair. There is no consensus regarding the necessity of concomitant cholecystectomy. (CCY) at the time of index surgery. This study aimed to evaluate the outcomes of gallstone ileus in patients with and without CCY.

Methods

Using the ACS NSQIP database from 2005 to 2019, we included patients who underwent surgical management of gallstone ileus (enterolithotomy) with or without CCY. The primary outcomes of interest were surgical site infection (SSI) and 30-day mortality. Additional outcomes of interest included readmissions related to the procedure, length of hospital stay (LOS), return to the operating room, and sepsis. Demographics were evaluated using univariate analysis, whereas outcomes of interest were analyzed using multivariate logistic regression.

Results

A total of 825 cases of gallstone ileus were identified among 118 patients who underwent cholecystectomy. Patient characteristics were similar between the groups. No concomitant cholecystectomy was associated with a longer hospital stay (8 days vs. five days, p<0.01) and tended to be more likely to return to the operating room (45 cases vs. 4 cases, p = 0.08), but this was not statistically significant. No concomitant CCY was associated with increased SSI rates, readmissions related to the procedure, 30-day mortality, or sepsis.

Conclusion

Surgical management of gallstone ileus with or without CCY has similar short-term postoperative outcomes.

Background

Over half of surgeries in the United States are performed on older adults. The aims of this study were to quantify geriatric-relevant discussion topics and assessments during the consent process and to assess the need for a structured approach to consent older patients.

Methods

General surgery residents at a single institution answered questions about content of the informed consent process and preoperative assessment in adult and geriatric (> 65) patients. Questions addressed frequency of geriatric- relevant discussions, assessments and consultations for the two patient groups.

Results

Part 1 was completed by 66/75 residents (88.0%). Most residents received training in informed consent during medical school or residency (95%). Common avenues for training were direct observation of attending surgeons or senior residents (85%), followed by didactic teaching (47%) and independent reading (30%). Only three residents (two PGY1s and one PGY2) reported receiving specific training in how to achieve informed consent in older patients. Part 2 was completed by 47/56 eligible residents (83.9%). Postoperative expectations (85.1%), living situation (53.2%), postoperative goals (53.2%), and advanced directives (42.6%) were most commonly discussed. Cognitive testing (19.1%), geriatrics consults (14.9%), and frailty scores (4.3%) were rarely addressed. There were no correlations between discussion of this information with resident age, level in residency, self-identified gender, or self-identification as a member of a racial or ethnic minority.

Conclusions

Geriatric-relevant topics and assessments occurred sporadically during the resident-led informed consent process and were more common with senior residents. Training in geriatric relevant informed consent rarely occurs during residency. These results, if generalizable across surgical training sites, highlight the need for a structured curriculum to address geriatric-relevant perioperative concerns.

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic commonly called COVID-19 brought new changes to healthcare delivery in the US. The purpose of this study is to identify the impact of COVID-19 on the delivery of acute surgical care for patients at a Level 1 trauma center during the lockdown period of the pandemic from March 13-May 1 2020.

Methods

All trauma admission to the University Medical Center Level 1 Trauma Center from March 13 to May 13, 2020, were retrospectively abstracted and compared to the same period during 2019. Analysis focused on the lockdown period of March 13-May 1, 2020, and compared to the same dates in 2019. Abstracted data included demographics, care timeframes, length of stay, and mortality. The data were analyzed using Chi-Square, Fisher Exact, and the Mann-Whitney U test.

Results

A total of 305 (2019) vs. 220 (2020) procedures were analyzed. No significant differences were seen in mean BMI, Injury Severity Score, American Society of Anesthesia Score, and Charlson Comorbidity Index between the two groups. Diagnosis time, interval to surgery, anesthesia time, surgical preparation time, operation time, transit time, mean hospital stay, and mortality were similar.

Conclusion

The results of this study demonstrate that the lockdown period of the COVID-19 pandemic did not significantly affect the trauma surgery service line, aside from case volume, at a Level 1 trauma center in West Texas during the lockdown period. Despite changes to healthcare delivery during the pandemic, care of surgical patients was conserved as timely and of high quality.

Objective

This study analyzed inpatient mortality and length of stay for lung cancer surgery in Illinois hospitals by patient clinical and demographic characteristics, procedure types, and hospital and surgeon volume.

Methods

The study analyzed lung cancer patients who underwent lobectomy or sublobar resection at Illinois hospitals from 2016 to June 2022. Trends in procedure type, inpatient mortality, one-day length of stay (LOS), and prolonged LOS (>10 days) were evaluated. Regression models were used to determine the likelihood of inpatient death and length of stay while controlling for clinical, procedure, hospital, and surgeon characteristics.

Results

There were 9602 admissions for lung cancer surgery at 89 non-federal Illinois hospitals. Overall, 0.7% of patients died, 12.2% of patients had one-day LOS, and 7.4% patients had prolonged LOS. From 2016 to 2022, rates of one-day LOS increased from approximately 5% to 23%, prolonged LOS dropped from almost 18% to under 5%, robotic lobectomies increased from <5% of procedures to over 40%, and VATS lobectomies went from almost 50% to 13%. The proportion of open lobectomy procedures remained stable. Robotic and VATS procedures were generally associated with better outcomes; however, VATS sublobar procedures were associated with worse LOS and mortality outcomes. Hospitals and surgeons with higher procedure volumes had significantly better outcomes.

Conclusions

Lung cancer surgery had low inpatient mortality and better LOS outcomes, with robotic steadily replacing VATS procedures. Higher hospital or surgeon volume was associated with better patient outcomes and may have been related to the greater utilization of Enhanced Recovery After Surgery Programs.

Background

Intestinal malrotation is a congenitally acquired condition of abnormally rotated proximal small bowel in neonates and infants. Prompt recognition prevents lifethreatening complications. A structured approach to diagnosing malrotation at UGIS is required for accurate diagnosis.

Objectives

Retrospective analysis of the images and radiological reports of UGIS, with the aim of identifying potential shortfalls in diagnosing malrotation. A secondary objective is to formulate a reporting template to improve overall quality of UGIS reports, specifically in cases of suspected malrotation.

Method

Identification and retrospective review of UGIS studies which were subsequently re-read by a blinded consultant radiologist using the proposed reporting template adapted from the literature.

Results

367 UGIS studies between 1 January 2016 and 31 December 2021 were included in the study cohort, which were then re-read. Using McNemar's chi-square test, we found discrepancy between the number of studies positive for malrotation on the original reports versus the re-read studies, highlighting shortfalls in our current practise.

Conclusion

A structured approach is paramount to the correct diagnosis of malrotation at UGIS. The position of the DJ-flexure (on frontal and lateral projections) proves most sensitive and specific in the diagnosis of malrotation at UGIS. Dedicated true lateral images were often found to be excluded in daily practise. We propose a structured inclusive reporting template.

Contribution

Our proposed standardized reporting template aims to improve radiological, clinical, and surgical outcomes at UGIS, specifically in patients with suspected malrotation.

Methods of pharyngoesophageal reconstruction include gastric pull-up, colon or jejunal interposition, and transfer of a free anterolateral thigh flap. The most popular method at our institution is transfer of a free jejunal graft. The free jejunum transfer was first described in 1957 by Seidenberg. The advantage of this procedure is a decreased risk of fistula, because the pharyngoesophagus is physiologically reconstructed with bowel-type reconstruction material. There are few reports about the operative methods of free jejunum transfer in detail and the operative methods vary greatly by institution. We performed free jejunum transfers for several hundred patients in the past and reported the characteristics and intraoperative and postoperative matters that require attention. Here, we summarize free jejunum transfer in oncologic reconstruction with relation to the points of safety, recipient vessels and microsurgical anastomosis, intestinal anastomosis and postoperative complications based on our experience and published reports.

Introduction

The incidence of post-operative urinary retention (POUR) following inguinal hernia repair (IHR) is approximately 0.4% - 22.0%. POUR may lead to patient discomfort and catheter-related complications including urinary tract infection, urethral trauma, bladder overdistension and subsequent permanent bladder dysfunction. We aimed to perform a systematic review and meta-analysis of randomised control trials (RCT) evaluating the impact of administration of perioperative alpha-blockade to reduce the incidence of acute POUR following IHR.

Methods

A systematic review was performed as per PRISMA guidelines. The incidence of POUR in the alpha-blocker and control groups were expressed as dichotomous outcomes, reported as odds ratios (ORs) expressed with 95% confidence intervals (CIs) following estimation using the Mantel-Haenszel method.

Results

Eight RCTs with a combined total of 918 patients were included. Of these, 53.7% (493/918) received alpha-blockers while 46.3% (425/918) did not. Five studies used tamsulosin, two used prazosin and one used phenoxybenzamine. Overall, the prescription of prophylactic alpha-blockers in the preoperative setting significantly reduced POUR compared to the control group (7.9% (39/493) vs 21.2% (90/425), OR: 0.31, 95% CI: 0.12–0.80, P = 0.020).

Conclusion

Preoperative prescription of alpha-blockers reduced the incidence of POUR following inguinal hernia repair. The next generation of prospective randomised trials may identify which patients should be prescribed this medication prior to surgery.

Background

Acute small bowel obstruction (aSBO) is the most common cause (76%) of acute intestinal obstruction. Laparoscopy use is still controversial in aSBO and indications not yet clearly defined. The aim of this study was to demonstrate the effectiveness and safety of a laparoscopic approach in aSBO by using specific pre-operative criteria for appropriate patient selection.

Methods

We retrospectively analyzed medical records of patients accepted at the Emergency Department for aSBO between January 2016 and March 2021 and performed a comparative analysis between types of treatment, considering demographics, clinical and radiological presentation, non-operative vs. operative management, intraoperative outcome, and postoperative course. We used a logistic regression to identify the variables related to surgical approach and built a predictive score upon the multivariable predictive model: the “SABO score”.

Results

198 patients were included in the study, of which 145 underwent surgery and 43 were successfully treated laparoscopically. Age and comorbidities were associated with open surgery (OR 3.2, 95% CI: 1.4–7.2, p = 0.006 and OR 2.7, 95% CI: 1.1–6.5, p = 0.023). A SABO score ≥ 0 identified an open approach with a sensitivity of 75.4% and a specificity of 69.8%.

Conclusions

Laparoscopy is growing in importance even in emergency settings. Our analysis suggests that a laparoscopic approach can be safe and feasible in aSBO management. Correct patient selection appears to be the key for a successful minimally invasive approach. SABO score therefore could be helpful in choosing the correct surgical strategy for patients with aSBO.

PROSPERO registration ID

367411

Objectives

This systematic review and meta-analysis was conducted to assess the outcome of streptococcal hip and knee prosthetic joint infection (PJI) treated with Debridement, Antibiotics and Implant Retention (DAIR) and to evaluate risk factors associated with failure.

Methods

We conducted a systematic literature search on PubMed, Embase, Web of Science, and Cochrane library from inception until October 2021. Random effects meta-analyses (i.e. relative risk) were used to estimate the success rate at the study level and its association with possible risk factors for failure with a specific focus on the use of rifampicin.

Results

25 observational studies were included, incorporating 1367 patients with streptococcal PJIs treated with DAIR. An overall pooled success rate of 71% (95% confidence interval (95%CI) 64–77%) was found for streptococcal PJI treated with DAIR. Treatment success was 76% (95%CI 62% to 91%) for knee PJI and 58% (95%CI 52% to 65%) for hip PJI. Treatment success differed for patients receiving rifampicin (84%, 95% CI 78% to 90%) compared to patients not receiving rifampicin (74%, 95% CI 63% to 85%), but this effect was no longer present in subsequent meta-analyses.

Conclusions

The meta-analysis showed no clear benefit for rifampicin administration after DAIR for streptococcal PJI. Better outcome was observed for knee PJI compared to hip PJI.