Surgery open science最新文献

Background

Previous reports identified an association between obese adolescents (OAs) and lower extremity (LE) fractures after blunt trauma. However, the type of LE fracture remains unclear. We hypothesized that OAs presenting after motor vehicle collision (MVC) have a higher risk of severe LE fracture and will require a longer length of stay (LOS) and more support services upon discharge, compared to non-OAs.

Methods

The 2017–2019 Trauma Quality Improvement Program database was queried for adolescents (12–17-years-old) presenting after MVC. The primary outcome was LE fracture. A severe fracture was defined by abbreviated injury scale ≥3. OAs were defined by a body mass index (BMI) ≥30.

Results

From 22,610 MVCs, 3325 (14.7 %) included OAs. The rate of any LE fracture was higher for OAs (21.6 % vs. 18.8 %, p < 0.001). On subset analysis the only LE fracture at higher risk in OAs was a femur fracture (13 % vs. 9.1 %, p < 0.001). After adjusting for sex and age, the risk for severe LE fracture (OR 1.34, CI 1.18–1.53, p < 0.001) was higher for OAs. OAs with a femur fracture had a longer median LOS (5 vs. 4 days, p = 0.003) and were more likely discharged with additional support services including home-health or inpatient rehabilitation (30.6 % vs. 21.4 %, p < 0.001).

Conclusion

OAs sustaining MVCs have increased associated risk of femur fractures. OAs are more likely to have a higher-grade LE injury, experience a longer LOS, and require additional support services upon discharge. Future research is needed to determine if early disposition planning with social work assistance can help shorten LOS.

Objectives

The optimal management of perforated appendicitis remains controversial. Many studies advocate for antibiotics and an interval appendectomy whereas others suggest that performing an appendectomy at the time of presentation decreases post-operative morbidity. Confounding this argument further are the patients who fail non-operative management and end up requiring surgery during their initial hospitalization. This study aims to determine if early operative intervention should be considered for perforated appendicitis.

Methods

This was a retrospective review of all patients who underwent an appendectomy (both laparoscopic or open) for perforated appendicitis between 2015 and 2020 at our institution.

Results

A total of 271 patients met inclusion criteria for this study. Of this group, 250 patients underwent an immediate appendectomy whereas the remaining 21 patients underwent a trial of non-operative management and eventually required an appendectomy during their initial admission. When comparing the immediate versus delayed operative groups, there were no differences in demographic data including age and gender, and no differences in various imaging findings including AAST Grade IV or V appendicitis. Operatively, patients in the delayed group had a longer operative time (83.1 ± 32.9 vs. 64.1 ± 26.2, p = 0.01), were more likely to require an open operation (23.8 % vs. 2.8 %, p < 0.0001), and were more likely to have a drain placed intra-operatively (42.9 % vs 14.4 %, p = 0.004). While there were no differences in 30-day readmission rates, patients in the delayed group had a significantly longer hospital length of stay than patients in the immediate group (9.4 ± 7.4 vs. 3.1 ± 3.3, p = 0.008).

Conclusions

Patients undergoing an immediate appendectomy for perforated appendicitis can discharge from the hospital sooner and demonstrate no increase in post-operative morbidity suggesting that surgeons can initially manage this disease process in an operative fashion.

Background

Patients with resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) sometimes show unexpected liver, peritoneal, and para-aortic lymph node metastases intraoperatively. Despite radical pancreatectomy, a nonnegligible number of patients relapse within 6 months after surgery. The aim of this study was to identify the preoperative predictors of occult metastases (OM), defined as intraoperative distant metastases or within 6 months after pancreatectomy.

Materials and methods

This study included patients with R and BR PDAC who underwent curative-intent pancreatectomy or staging laparoscopy between 2006 and 2021. Multivariate logistic regression and Cox hazard analyses were performed to identify the preoperative predictors of OM and to assess the impact of these factors on prognosis after pancreatectomy.

Results

Of the 279 patients, OM was observed intraoperatively in 47 and postoperatively in 34. In the OM group, there were no differences in prognosis between patients who had intraoperative metastases and recurrence within 6 months (median survival time [MST], 18.1 vs. 12.9 months), and between patients who underwent pancreatectomy and those who did not (MST, 13.9 vs. 18.1 months). Preoperative tumor size ≥22 mm (odds ratio [OR], 2.03; 95 % confidence interval [CI], 1.16–3.53; p = 0.013) and preoperative CA19–9 level ≥ 118.8 U/mL (OR, 2.64; 95 % CI, 1.22–5.73; p = 0.014) were significant predictors of OM. Additionally, positive OM predictors were strong independent prognostic factors for overall survival after pancreatectomy (hazard ratio, 2.47; 95 % CI, 1.54–3.98; p < 0.001).

Conclusion

Multidisciplinary treatment strategies should be considered for patients with predictors of OM to avoid inappropriate surgical interventions.

Background

There is a paucity of literature guiding trauma surgeons in the care of patients with active metastatic cancer (MC). Even less is known regarding outcomes for MC patients requiring emergent surgery after trauma. We hypothesized that trauma patients with active Metastatic Cancer (MC) have an increased mortality rate and undergo increased rates of withdrawal of care (WoC) within 72-hours following emergent operations, compared to similarly matched patients without MC.

Methods

Patients with active MC at the time of traumatic injury were matched 1:2 against patients without active MC based on demographics, comorbidities, vital signs on admission, and injury profile.

Results

From 43,826 patients, 0.2 % had MC. After matching 39 MC patients to 78 without MC, there was no difference in demographics, comorbidities, injury severity score, mechanism of injury, vitals on admission (blood pressure, heart rate, respiration rate) and need for blood transfusion (all p > 0.05). Compared to patients without MC, patients with MC had higher rates and associated risk of death during index hospitalization (38.5 % vs. 15.2 %, p = 0.005; OR 3.49, CI 1.43–8.51, p = 0.006), as well as a higher rate and associated risk of WoC within 72-hours (12.8 % vs. 1.3 %, p = 0.007; OR 11.47, CI 1.29–101.93, p = 0.029).

Conclusion

Trauma patients with MC requiring emergent thoracic or abdominal surgery have a high risk of death and an over ten-fold higher associated risk for WoC within the first three days. In some cases, palliative care consultation should be considered, and counseling should be offered to this high-risk trauma population to enable individualized and patient-centric decisions.

Key message

This research highlights the importance of a multidisciplinary team consisting of trauma surgeons, oncologist, and palliative care physicians in caring for the high-risk trauma patients with disseminated cancer requiring urgent surgery.

Objective

This single-centre retrospective study aims to determine the incidence of therapy-induced surgical benefit in patients with non-metastatic gastrointestinal stromal tumour (GIST) treated with neoadjuvant tyrosine kinase inhibitors (TKI) and evaluate whether this can be predicted by radiological response criteria.

Methods

Thirty-nine non-metastatic GIST patients were treated with neoadjuvant TKI treatment, followed by curative-intended surgery, and monitored using contrast-enhanced computed tomography (CE-CT). Surgical benefit was independently assessed by two surgical oncologists and was defined by de-escalation of surgical strategy or reduced surgical complexity. Radiological response between baseline and the last preoperative scan was determined through RECIST 1.1, Choi and volumetric criteria.

Results

In this patient cohort, median neoadjuvant treatment interval was 8.3 (IQR, 3.9–10.6) months. Surgical benefit was gained in 22/39 patients. When comparing radiological criteria to findings on surgical benefit, accuracy, sensitivity, and specificity for RECIST 1.1 (90 %, 100.0 % and 82 %), Choi (64 %, 24 %, and 96 %) and volumetry (95 %, 100.0 %, and 91 %) were calculated. In 30/39 patients, temporal changes in tumour size over the course of treatment was assessed. Tumour volume reduced significantly in the surgical-benefit group compared to the non-benefit group (72 % vs. 25 %, p < 0.01) within three months. 14/19 surgical-benefit patients had an initial volume reduction above 66 %, after which volume reduced slightly with a median 3.1 % (IQR, 2.1–7.8 %) reduction.

Conclusion

Surgical benefit after neoadjuvant treatment was achieved in 56 % of patients and was most accurately reflected by size-based response criteria. In patients with therapy-induced surgical benefit, nearly all treatment-induced volume reductions were achieved within three months.

Background

Surgical residency training is prominently demanding and stressful. This can affect the residents' wellbeing, work-life balance and increase the rates of burnout. We aimed to assess rates of satisfaction and burn-out among GS residents in the national training programs and provide a subsequent in-depth analysis of the potential reasons.

Method

A sequential explanatory mixed-methods study was conducted using an online survey and virtual interviews. The validated abbreviated Maslach Burnout Inventory (aMBI) was used to assess burnout while satisfaction was assessed via 5-points Likert scale.

Results

After excluding incomplete responses from the total 74 received, 53 were analyzed. The average participant age was 27.4 ± 2 years, with females comprising 52 % of the sample. Junior residents made up 58.5 %, and nearly half −45 %- considered quitting GS training. Moderate to high burnout rates were noted on each aMBI subscale, ranging from 41.7 % to 62.5 %. The majority of residents expressed dissatisfaction with the level of research engagement (81.1 %), supervision, and mentorship. However, operative exposure was a source of satisfaction. Dissatisfaction rates with intra-operative learning, academia, teaching, and clinical exposure were 62.3 %, 52.8 %, 50.9 %, and 35.8 %, respectively. Interviews revealed surgical case flow and a friendly work environment as major satisfaction sources. Conversely, lack of academic supervision and suboptimal hands-on training were major dissatisfaction sources.

Conclusion

Dissatisfaction and burn-out is prevalent among national GS training programs. Sub-optimal educational delivery and low-quality hands-on operative exposure -rather than lack of exposure to cases- seem to be the culprit.

Background

Noise is omnipresent in the operating room. The average noise in the operating room generally ranges between 60 and 65 dB and can sometimes exceed 100 dB, despite the ARS (Agence Régionale de Santé) and WHO (World Health Organization) recommending levels of 35 dB(A). This study aimed to evaluate the effect of different kinds of background auditory stimuli on the performance of surgeons during an arthroscopic simulation task.

Methods

Forty-seven surgeons with varying experience in arthroscopic surgery undertook different exercises under four different conditions: quiet, classical music, hard rock, and sustained chatter. All background auditory stimuli were set at 65 dB(A). Each participant underwent double randomization for the four sound stimuli and the four exercises to be performed. A musical questionnaire was also completed by each participant. Data related to each exercise included operating time in seconds, distance from the camera or instruments in centimeters, and an overall score automatically calculated by the simulator based on safety, economy of movement, and speed (scale: 0–20 points).

Results

Operative time in an environment with classical music was significantly lower than in an environment with hard rock (95.9 s vs. 128.7 s, p = 0.0003). The overall rating in an environment with chatter was significantly lower than in a silent environment (11.7 vs. 15.7, p < 0.0001). The overall rating in an environment with hard rock was significantly lower than in an environment with classical music (14.3 vs. 17.5, p = 0.0008).

Surgeons who preferred listening to music in the operating room performed differently than those who did not. The mean operative time for surgeons who preferred music was 99.52 s (SD = 47.20), compared to 117.16 s (SD = 61.06) for those who did not prefer music, though this difference was not statistically significant (p = 0.082). The mean overall score for surgeons who preferred music was significantly higher at 17.46 (SD = 2.29) compared to 15.57 (SD = 3.49) for those who did not prefer music (p = 0.001).

Conclusions

Our study suggests that exposure to classical music and silence may confer greater benefits to the surgeon compared to the impact of hard rock and chatter. These conclusions are grounded in significant differences observed in operative time and overall evaluations, highlighting the potential advantages of an environment characterized by acoustic tranquility for surgical professionals. Preferences for music in the operating room also play a role, with those who prefer music demonstrating better performance scores.

The implementation of screening colonoscopy with polyp removal has significantly decreased mortality rates associated with colorectal cancer (CRC), although it remains a major cause of cancer-related deaths globally. CRC typically originates from adenomatous polyps, and increased removal of these growths has led to reduced CRC incidence and mortality. Endoscopic polypectomy techniques, including hot and cold snare polypectomy, play a pivotal role in this process. While both methods are effective for small polyps (<10 mm), recent evidence favors cold snare polypectomy due to its superior safety profile and comparable complete resection rates. Large polyps (>10 mm), particularly those with advanced features, pose increased cancer risks and often require meticulous assessment and advanced endoscopic techniques, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), for resection.

This chapter also provides a practical overview of endoscopic techniques for managing colonic obstructions and pericolonic fluid collections, detailing their indications, advantages, disadvantages, and complications. The goal is to improve understanding and application in clinical practice. Additionally, we provide a summary of endoscopic closure techniques that have revolutionized the management of perforations and fistulas, offering safe and effective alternatives to surgery.

Objectives

Advancements in technology have spurred a transformative shift in medical education, with virtual reality (VR) emerging as a powerful tool for enhancing the learning experience. This study analyses the publications of VR in medical education, focusing on differences within different medical specialties.

Design

Using specific search terms, all studies published on VR in medical education listed in the Web of Science databases were included. All identified publications were analysed in order to draw comparative conclusions regarding their qualitative and quantitative scientific merit.

Results

Since the first publication in 1993 and until the year 2022, there have been 1534 publications on VR in medical education. Over the years, the annual publication rate has increased almost exponentially. The studies have in total been cited 42,655 times (average 27.64 citations/publication). The leading medical field was surgery (415 publications), followed by internal medicine (117 publications), neurology (77 publications) and radiology and nuclear medicine (75 publications). Internationally, the United States (560 publications), the United Kingdom (179 publications), Canada (156 publications), Germany (139 publications) and China (100 publications) are the leading countries in this field. 37.1 % of the publications reported having received funding. Among the 100 organizations with the highest number of grants, only 8 were private companies.

Conclusion

During the last 30 years, there has been a consistent rise in publications, with a notable surge observed in 2016 and 2020. The majority of the studies centered on surgical concerns. However, only a small proportion received financial support, which was particularly evident for funding originating from the private sector.

Background

The COVID-19 pandemic negatively impacted the collective American psyche. Socioeconomic hardships including social isolation led to an increase in firearm sales. Previous regional studies demonstrated increased penetrating trauma during the pandemic but it is unclear if trauma systems were prepared for this influx of penetrating injuries. This study aimed to confirm this increased penetrating trauma trend nationally and hypothesized penetrating trauma patients treated during the pandemic had a higher risk of complications and death, compared to pre-pandemic patients.

Methods

The 2017–2020 Trauma Quality Improvement Program database was divided into pre-pandemic (2017–2019) and pandemic years (2020). Bivariate analyses and a multivariable logistic regression analyses were performed controlling for age, comorbidities, injuries, and vitals on arrival.

Results

From 3,525,132 patients, 936,890 (26.6 %) presented during the pandemic. The pandemic patients had a higher rate of stab-wounds (4.8 % vs. 4.5 %, p > 0.001) and gunshot wounds (5.8 % vs. 4.6 %, p < 0.001) compared to pre-pandemic patients. Among penetrating trauma patients, the rate and associated risk of in-hospital complications (5.0 % vs. 5.1 %, p = 0.38) (OR 0.98, CI 0.94–1.02, p = 0.26) was similar between pre-pandemic and pandemic cohorts but adjusted risk of mortality decreased during the pandemic (8.3 % vs. 8.3 %, p = 0.45) (OR 0.92, CI 0.89–0.96, p < 0.001).

Conclusion

This national analysis confirms an increased rate of penetrating trauma during the COVID-19 pandemic, with a higher rate of gunshot injuries. However, this did not result in an increased risk of death or complications suggesting that trauma systems across the country were prepared to handle a dual pandemic of COVID and firearm violence.