bluuebunny/crossref_metadata_2025 huggingface dataset:
Nutritional challenges in patients with gastroparesis
Authors: Aguilar Ariadna , Malagelada Carolina , Serra Jordi
Published: July 2022

Purpose of review

Our purpose was to review the most recent publications on nutritional management in gastroparesis, and their relevance for global management of gastroparesis.

Recent findings

The last months, several reviews on gastroparesis have been published as well as excellent reviews on the nutritional management of patients suffering this condition. In these publications, the relevance of nutrition in management of gastroparesis has been highlighted. However, alarming studies have been published from several authors from Europe and the United States showing that a majority of patients did not follow any dietary advice from a specialist in nutrition, most patients start restrictive diets by their own, and that as much as 60% of patients have a caloric-deficient diet. In addition, recent studies show that some of the recommendations, like a radical exclusion of fibers from the diet, may be reconsidered taking into account the potential beneficial effects of fibers in global health.

Nutritional interventions are one of the cornerstones in management of gastroparesis. Consequently, an interdisciplinary approach, with managing teams composed by gastroenterologist and specialist in nutrition should be the correct strategy to achieve the best outcomes in symptom control and prevention of complications related to nutritional deficits.

Video abstract

http://links.lww.com/COCN/A17
Zinc Kinetics Correlate With Length-for-Age z Scores in Bangladeshi Infants
Authors: Wastney Meryl E. , Long Julie M. , McDonald Christine M. , Krebs Nancy F. , Islam M. Munirul , Ahmed Tahmeed , Khandaker Afsana Mim , Sthity Rahvia Alam , Westcott Jamie E. , King Janet C.
Published: July 2022

Objectives:

Stunting [length-for-age z score (LAZ) <−2] has multiple causes and is prevalent in areas with low dietary zinc (Zn) intake. Zinc kinetics from non-stunted infants were used in a published model for predicting linear growth; here, we directly measure zinc kinetics in stunted infants.

Methods:

Zinc kinetics were determined in 9-month-old Bangladeshi infants (n = 10), who were non-wasted [weight-for-length z score (WLZ) >−2], ranging in LAZ from −2.9 to −0.43. Stable isotopes were administered 2 hours after a meal as oral (70Zn) and intravenous (67Zn) tracers. After isotope administration, blood was sampled within 5 hours and all urine and feces were collected for 24 hours. Urine was sampled twice-daily out to 9 days. Data were analyzed by compartmental modeling. Daily zinc intake was estimated by the model as the sum of zinc used for growth plus that lost via urine and feces. Zinc absorbed (the amount required to maintain steady state) was the sum of zinc used for growth plus urine and endogenous fecal excretions.

Results:

The LAZ score correlated with serum zinc concentration (R = 0.77, P = 0.001), urinary zinc excretion (R = 0.66, P = 0.010), and fractional zinc absorption from calculated daily intake (R = 0.58, P = 0.030). In stunted infants (n = 8), the amount of zinc absorbed did not increase with calculated zinc intake unlike published values for non-stunted infants.

Conclusions:

Zinc kinetics in Bangladeshi infants correlate with LAZ and show that malabsorption of supplemental sources of zinc may occur in stunted infants.
Denials, Dilly-dallying, and Despair: Navigating the Insurance Labyrinth to Obtain Medically Necessary Medications for Pediatric Inflammatory Bowel Disease Patients
Authors: Kahn Stacy A. , Bousvaros Athos
Published: July 2022

Increasingly, in the United States, the prescribing of high-cost drugs has become a challenge for physicians and other practitioners. Such drugs are highly regulated by third-party payers (aka insurance), as well as pharmacy benefit managers. Not infrequently, a clinician prescribing a medication will have the payment for the prescription denied by the third-party payer, with the end result being a delay in getting a medically necessary medication to a patient. This article highlights the challenges involved in the prior authorization and denial process, with a focus on pediatric inflammatory bowel disease. The article reviews the role of pharmacy benefits managers in restricting access to drugs, and the reasons why denials of medically necessary medications may occur. The article also provides information on how to appeal denials, how to write a letters of medical necessity, and how to conduct a proper peer-to-peer review. Advocacy from patients and clinicians will be important, as we want to reform the process in the future.
SPECT/CT Lymphoscintigraphy Guidance Simplifies and Improves Targeted Axillary Dissection of the Clipped Nodes After Neoadjuvant Chemotherapy in Initially Node-Positive Breast Cancer
Authors: Has Simsek Duygu , Emiroglu Selman , Yilmaz Ravza , Bayram Aysel , Isik Emine Goknur , Tukenmez Mustafa , Kuyumcu Serkan , Dursun Memduh , Muslumanoglu Mahmut , Cabioglu Neslihan
Published: July 2022

Purpose

We assessed the feasibility of SPECT/CT lymphoscintigraphy (99m Tc-nanocolloid) method to simplify and improve targeted axillary dissection of clipped axillary lymph node (axLN) after neoadjuvant chemotherapy (NAC) in initially node-positive breast cancer.

Patients and Methods

Fifteen patients who had clip placement to biopsy-confirmed axLN metastasis due to clinically node-positive breast cancer before NAC and underwent SPECT/CT lymphoscintigraphy for surgery after NAC were included into the study. SPECT/CT lymphoscintigraphy was performed to localize the clipped node and to assess if the clipped lymph node (LN) had 99mTc-nanocolloid uptake or not. In case the clipped node had no uptake on SPECT/CT, the patient was referred to wire-guided localization procedure. Blue dye was also injected for dual mapping of sentinel LN biopsy.

Results

All patients had only ipsilateral axLN metastasis. SPECT/CT lymphoscintigraphy showed that clipped LNs were radioavid in 12 of 15 patients (80%). Clipped LNs were not blue-stained in 5 patients (33.3%), and in 2 of them, clipped LNs were radioavid in SPECT/CT. Wire-guided localization was required in only 3 patients (20%) for nonradioavid/blue-stained clipped LNs. Removal of the clipped nodes was confirmed in all cases with a success rate of 100% by specimen graphy.

Conclusion

SPECT/CT lymphoscintigraphy seems feasible to determine the clipped LNs intraoperatively without requiring additional invasive methods in most of the patients. This technique simplifies and improves targeted axillary dissection of the clipped axLNs after NAC in initially node-positive breast cancer and can be adapted to clinical practice with further investigations.
Real-world Evaluation of the Efficacy of Neoadjuvant DCF Over CF in Esophageal Squamous Cell Carcinoma
Authors: Matsuda Satoru , Kitagawa Yuko , Takemura Ryo , Okui Jun , Okamura Akihiko , Kawakubo Hirofumi , Muto Manabu , Kakeji Yoshihiro , Takeuchi Hiroya , Watanabe Masayuki , Doki Yuichiro
Published: July 2022

Objective:

We aimed to evaluate the efficacy of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (DCF) therapy over cisplatin and 5-fluorouracil (CF) in patients with surgically resectable advanced esophageal squamous cell carcinoma (ESCC), using real-world data from 85 esophageal centers.

Background:

JCOG1109 trial, which assessed the superiority of DCF over CF, and the superiority of chemoradiotherapy with CF over CF alone demonstrated the significant survival advantage of neoadjuvant DCF in overall survival (OS) over CF for ESCC.

Methods:

The ESCC patients who received neoadjuvant CF or DCF at 85 Japanese esophageal centers certified by the Japan Esophageal Society were retrospectively reviewed. After propensity score (PS) matching, the OS and recurrence-free survival were compared between CF and DCF.

Results:

We initially enrolled 4781 patients. After data cleaning and PS matching using pretreatment variables, 1074 patients for each group were selected for subsequent analysis. There was no significant difference in the incidence of postoperative pneumonia and anastomotic leakage. In the survival analysis, OS was significantly longer in DCF group than CF group (hazard ratio, 0.868; 95% confidence interval, 0.770–0.978; P=0.02), as well as recurrence-free survival (hazard ratio, 0.850; 95% confidence interval, 0.761–0.949; P=0.004). The survival advantage of DCF was not observed in patients with 76 years old or older.

Conclusions:

Neoadjuvant DCF therapy showed a remarkable survival advantage in surgically resectable ESCC patients, especially in patients who were 75 years old or younger. The current real-world evidence will encourage recommendations for DCF as a standard regimen in neoadjuvant chemotherapy–based treatment strategy for ESCC.
Baseline Assessments of Psychomotor Aptitude Are Associated With the Future Operative Performance of Surgical Trainees
Authors: Toale Conor , Morris Marie , Ryan Donncha M. , Boland Fiona , Doherty Eva M. , Traynor Oscar J. , Kavanagh Dara O.
Published: July 2022

Objective:

This study sought to investigate the association between validated psychomotor ability tests and future in-theater and simulated operative performance.

Background:

Assessments of visuospatial ability, perceptual ability, and manual dexterity correlate with simulated operative performance. Data showing the predictive value of such assessments in relation to future performance in the workplace is lacking.

Methods:

Core surgical residents in Ireland recruited from 2016 to 2019 participated in assessments of baseline perceptual, visuospatial, and psychomotor ability; Pictorial Surface Orientation (PicSOr) testing, digital visuospatial ability testing, and manual dexterity testing. Operative performance was prospectively assessed using the in-theater Supervised Structured Assessment of Operative Performance (SSAOP) tool, and simulation-based Operative Surgical Skill (OSS) assessments performed over a 2-year core training period. SSAOP assessments were scored using a 15-point checklist and a global 5-point operative performance score. OSS assessments were scored using procedure-specific checklists. Univariate correlations and multiple linear regression analyses were used to explore the association between fundamental ability measures and operative performance.

Results:

A total of 242 residents completed baseline psychomotor ability assessments. Aggregated fundamental ability scores were associated with performance in submitted workplace-based SSAOP assessments using the Total Checklist score (P=0.002) and Overall Performance scores (P=0.002), independent of operative experience, and undergraduate centile scores. Aggregated ability scores were also positively associated with simulation-based OSS assessment scores on multivariable analysis (P=0.03).

Conclusion:

This study indicates that visuospatial, psychomotor, and perceptual ability testing scores are associated with the future operative performance of surgical residents.
Parental Support Policies and Benefits: A Surgical Training Program Report Card of Transparency
Authors: Rangel Erika L. , Castillo-Angeles Manuel , Marincola Smith Paula , Terhune Kyla P.
Published: July 2022

Objective:

This study aimed to investigate the transparency of parental benefits available to US surgical residency applicants.

Background:

Medical students prioritize work-family balance in specialty selection. Those applying to surgical residency programs also place a significant value on parental leave policies when deciding where to train. However, little is known about the amount of information that surgical training programs publicly offer to potential applicants regarding family support policies.

Methods:

Publicly available websites for 264 general surgery training programs were accessed to determine the availability of information on parental benefits. Twenty-six “items of transparency” included types of leave, contract flexibility, salary, lactation, and childcare support. Programs with fewer than the median items of transparency were contacted to inquire about additional public resources. Academic programs were stratified by their associated medical school rankings in the US News & World Report.

Results:

A total of 144 (54%) programs were academic and 214 (81.4%) had male program directors. The median number of items of transparency was 8 (29.6%). Of the 131 programs contacted, 33 (25.9%) replied, and 2 (6.1%) improved their transparency score. Academic programs associated with medical schools in the upper third of the rankings were more likely to have ≥8 items of transparency (70.8% vs. 45.6%; P=0.002). In the adjusted analysis, academic programs [odds ratio (OR): 3.44, 95% confidence interval (95% CI): 1.87–6.34], those with female program directors (OR: 2.09, 95% CI: 1.01–4.33), and those located in the Western (OR: 3.13, 95% CI: 1.31–7.45) and Southern (OR: 2.45, 95% CI: 1.21–4.98) regions of the country were more likely to have ≥8 items of transparency.

Conclusions:

There are significant deficits in publicly available information related to parental benefits for many surgical training programs, which may impact applicants’ decision making. Attracting the most talented candidates requires programs to create and share policies that support the integration of professional and personal success.
Conduits in Vascular Pancreatic Surgery
Authors: Kinny-Köster Benedict , Habib Joseph R. , van Oosten Floortje , Javed Ammar A. , Cameron John L. , Burkhart Richard A. , Burns William R. , He Jin , Wolfgang Christopher L.
Published: July 2022

Objectives:

We analyze successes and failures of pushing the boundaries in vascular pancreatic surgery to establish safety of conduit reconstructions.

Background:

Improved systemic control from chemotherapy in pancreatic cancer is increasing the demand for surgical solutions of extensive local vessel involvement, but conduit-specific data are scarce.

Methods:

We identified 63 implanted conduits (41% autologous vessels, 37% allografts, 18% PTFE) in 56 pancreatic resections of highly selected cancer patients between October 2013 and July 2020 from our prospectively maintained database. Assessed parameters were survival, perioperative complications, operative techniques (anatomic and extra-anatomic routes), and conduit patency.

Results:

For vascular reconstruction, 25 arterial and 38 venous conduits were utilized during 39 pancreatoduodenectomies, 14 distal pancreatectomies, and 3 total pancreatectomies. The median postoperative survival was 2 years. A Clavien-Dindo grade ≥IIIa complication was apparent in 50% of the patients with a median Comprehensive Complication Index of 29.6. The 90-day mortality in this highly selected cohort was 9%. Causes of mortality were conduit related in 3 patients, late postpancreatectomy hemorrhage in 1 patient, and early liver metastasis in 1 patient. Image-based patency rates of conduits were 66% and 45% at postoperative days 30 and 90, respectively.

Conclusions:

Our perioperative mortality of vascular pancreatic surgery with conduits in the arterial or venous system is 9%. Reconstructions are technically feasible with different anatomic and extra-anatomic strategies, while identifying predictors of early conduit occlusion remains challenging. Optimizing reconstructed arterial and venous hemodynamics in the context of pancreatic malignancy will enable long-term survival in more patients responsive to chemotherapies.
European Multicentric Experience With Fenestrated-branched ENDOvascular Stent Grafting After Previous FAILed Infrarenal Aortic Repair
Authors: Budtz-Lilly Jacob , D’Oria Mario , Gallitto Enrico , Bertoglio Luca , Kölbel Tilo , Lindström David , Dias Nuno , Lundberg Goran , Böckler Dittmar , Parlani Gianbattista , Antonello Michele , Veraldi Gian F. , Tsilimparis Nikolaos , Kotelis Drosos , Dueppers Philip , Tinelli Giovanni , Ippoliti Arnaldo , Spath Paolo , Logiacco Antonino , Schurink Geert Willem H. , Chiesa Roberto , Grandi Alessandro , Panuccio Giuseppe , Rohlffs Fiona , Wanhainen Anders , Mani Kevin , Karelis Angelos , Sonesson Björn , Jonsson Magnus , Bresler Alina-Marilena , Simonte Gioele , Isernia Giacomo , Xodo Andrea , Mezzetto Luca , Mastrorilli Davide , Prendes Carlota F. , Chaikhouni Basel , Zimmermann Alexander , Lepidi Sandro , Gargiulo Mauro , Mees Barend , Unosson Jon
Published: July 2022

Objective:

To report the mid-term outcomes of fenestrated-branched endovascular aneurysm repair (F-BEVAR) following a failed previous endovascular aneurysm repair (pEVAR) or previous open aneurysm repair (pOAR).

Methods:

Data from consecutive patients who underwent F-BEVAR for pEVAR or pOAR from 2006 to 2021 from 17 European vascular centers were analyzed. Endpoints included technical success, major adverse events, 30-day mortality, and 5-year estimates of survival, target vessel primary patency, freedom from reinterventions, type I/III endoleaks, and sac growth >5 mm.

Background:

Treatment of a failed previous abdominal aortic aneurysm repair is a complex undertaking. F-BEVAR is becoming an increasingly attractive option, although comparative data are limited regarding associated risk factors, indications for treatment, and various outcomes.

Results:

There were 526 patients included, 268 pOAR and 258 pEVAR. The median time from previous repair to F-BEVAR was 7 (interquartile range, 4–12) years, 5 (3–8) for pEVAR, and 10 (6–14) for pOAR, P<0.001. Predominant indication for treatment was type Ia endoleak for pEVAR and progression of the disease for pOAR. Technical success was 92.8%, pOAR (92.2%), and pEVAR (93.4%), P=0.58. The 30-day mortality was 6.5% overall, 6.7% for pOAR, and 6.2% for pEVAR, P=0.81. There were 1853 treated target vessels with 5-year estimates of primary patency of 94.4%, pEVAR (95.2%), and pOAR (94.4%), P=0.03. Five-year estimates for freedom from type I/III endoleaks were similar between groups; freedom from reintervention was lower for pEVAR (38.3%) than for pOAR (56.0%), P=0.004. The most common indication for reinterventions was for type I/III endoleaks (37.5%).

Conclusions:

Repair of a failed pEVAR or pOARis safe and feasible with comparable technical success and survival rates. While successful treatment can be achieved, significant rates of reintervention should be anticipated, particularly for issues related to instability of target vessels/bridging stents.
The Nissen-Hill Hybrid Repair
Authors: Aye Ralph W. , Baison George N. , Ahmed Hassan , Watkins Jeffery , DeMeester Steven R. , Bograd Adam J. , Farivar Alexander S. , Louie Brian E.
Published: July 2022

Introduction:

A new repair for gastroesophageal reflux and hiatal hernia, the Nissen-Hill hybrid repair, was developed to combine the relative strengths of its component repairs with the aim of improved durability. In several small series, it has been shown to be safe, effective, and durable for paraesophageal hernia, Barrett esophagus, and gastroesophageal reflux disease. This study represents our experience with the first 500 consecutive repairs for all indications.

Methods:

Retrospective study of prospectively collected data for the first 500 consecutive Nissen-Hill hybrid repairs from March 2006 to December 2016, including all indications for surgery. Three quality of life metrics, manometry, radiographic imaging, and pH testing were administered before and at defined intervals after repair.

Results:

Five hundred patients were included, with a median follow-up of 6.1 years. Indications for surgery were gastroesophageal reflux disease in 231 (46.2%), paraesophageal hernia in 202 (40.4%), and reoperative repair in 67 (13.4%). The mean age was 59, with body mass index of 30 and 63% female. A minimally invasive approach was used in 492 (98%). Thirty-day operative mortality was 1 (0.2%), with a 4% major complication rate and a median length of stay of 2 days. Preoperative to postoperative pH testing was available for 390 patients at a median follow-up of 7.3 months, with the median DeMeester score improving from 45.9 to 2.7. At long-term follow-up (229 responses), all median quality of life scores improved: Quality Of Life in Reflux And Dyspepsia 4 to 6.9, Gastroesophageal Reflux Disease-Health Related Quality of Life 22 to 3, and Swallowing 37.5 to 45 and proton pump inhibitor use dropped from 460 (92%) to 50 (10%). Fourteen (2.8%) underwent reoperation for failure.

Conclusion:

The combined Nissen-Hill hybrid repair is safe and effective in achieving excellent symptomatic and objective outcomes and low recurrence rates beyond 5 years.
Comparative Experience of Short-wavelength Versus Long-wavelength Fluorophores for Intraoperative Molecular Imaging of Lung Cancer
Authors: Kennedy Gregory T. , Azari Feredun S. , Chang Ashley , Nadeem Bilal , Bernstein Elizabeth , Segil Alix , Din Azra , Marfatia Isvita , Desphande Charuhas , Okusanya Olugbenga , Keating Jane , Predina Jarrod , Newton Andrew , Kucharczuk John C. , Singhal Sunil
Published: July 2022

Background:

Intraoperative molecular imaging (IMI) using tumor-targeted optical contrast agents can improve cancer resections. The optimal wavelength of the IMI tracer fluorophore has never been studied in humans and has major implications for the field. To address this question, we investigated 2 spectroscopically distinct fluorophores conjugated to the same targeting ligand.

Methods:

Between December 2011 and November 2021, patients with primary lung cancer were preoperatively infused with 1 of 2 folate receptor-targeted contrast tracers: a short-wavelength folate-fluorescein (EC17; λem=520 nm) or a long-wavelength folate-S0456 (pafolacianine; λem=793 nm). During resection, IMI was utilized to identify pulmonary nodules and confirm margins. Demographic data, lesion diagnoses, and fluorescence data were collected prospectively.

Results:

Two hundred eighty-two patients underwent resection of primary lung cancers with either folate-fluorescein (n=71, 25.2%) or pafolacianine (n=211, 74.8%). Most tumors (n=208, 73.8%) were invasive adenocarcinomas. We identified 2 clinical applications of IMI: localization of nonpalpable lesions (n=39 lesions, 13.8%) and detection of positive margins (n=11, 3.9%). In each application, the long-wavelength tracer was superior to the short-wavelength tracer regarding depth of penetration, signal-to-background ratio, and frequency of event. Pafolacianine was more effective for detecting subpleural lesions (mean signal-to-background ratio=2.71 vs 1.73 for folate-fluorescein, P<0.0001). Limit of signal detection was 1.8 cm from the pleural surface for pafolacianine and 0.3 cm for folate-fluorescein.

Conclusions:

Long-wavelength near-infrared fluorophores are superior to short-wavelength IMI fluorophores in human tissues. Therefore, future efforts in all human cancers should likely focus on long-wavelength agents.
Performance of quick sequential organ failure assessment and modified age disease adjusted qadSOFA for the prediction of outcomes in emergency general surgery patients
Authors: Magyar Christian T. J. , Haltmeier Tobias , Dubuis Jean-Baptiste , Osterwalder Alice , Winterhalder Sebastian , Candinas Daniel , Schnüriger Beat
Published: July 2022

BACKGROUND

Sepsis is a highly prevalent condition and is associated with a reported in-hospital mortality rate up to 40% in patients with abdominal sepsis requiring emergency general surgery (EGS). The quick sequential organ failure assessment score (qSOFA) has not been studied for EGS patients.

METHODS

Retrospective cohort study in adult patients undergoing abdominal EGS at a university tertiary care center from 2016 to 2018. The primary outcome was mortality. The effect of clinical variables on outcomes was assessed in univariable and multivariable logistic regression analyses. Based on these results, the qSOFA score was modified. The performance of scores was assessed using receiver operating characteristics.

RESULTS

Five hundred seventy-eight patients undergoing abdominal EGS were included. In-hospital mortality was 4.8% (28/578). Independent predictors for mortality were mesenteric ischemia (odds ratio [OR] 15.9; 95% confidence interval [CI] 5.2–48.6; p < 0.001), gastrointestinal tract perforation (OR 4.9; 95% CI 1.7–14.0; p = 0.003), 65 years or older (OR 4.1; 95% CI 1.5–11.4; p = 0.008), and increasing qSOFA (OR 1.8; 95% CI 1.2–2.8; p = 0.007). The modified qSOFA (qadSOFA) was developed. The area under the receiver operating characteristic curve of the qSOFA and qadSOFA for mortality was 0.715 and 0.859, respectively. Optimal cutoff value was identified as qadSOFA ≥ 3 (Youden Index 64.1%).

CONCLUSION

This is the first study investigating the qSOFA as a predictor for clinical outcomes in EGS. Compared with the qSOFA, the new qadSOFA revealed an excellent predictive power for clinical outcomes. Further validation of qadSOFA is warranted.

LEVEL OF EVIDENCE

Diagnostic test/criteria; Level II.
The Role of Donor Sex in Females Undergoing Repeat Kidney Transplant: Does Prior Donor Sex Matter?
Authors: Craig Stephanie , Tennankore Karthik , Kiberd Bryce , Worthen George , Vinson Amanda
Published: July 2022

Background.

Female recipients of male donor kidneys are at increased risk for graft failure because of the HY antigen effect. However, whether prior transplant with a male donor impacts subsequent transplant outcomes is unknown. Therefore, the purpose of this study was to determine whether prior male-current male donor sex is associated with an increased risk of graft failure in female recipients.

Methods.

We performed a cohort study of adult female recipients undergoing a second kidney transplant (2000–2017), identified using the Scientific Registry of Transplant Recipients. Using multivariable Cox models, we analyzed the risk of death-censored graft loss (DCGL) if the second transplant was from a male versus female kidney donor, conditional on donor sex at the time of the first transplant. In a secondary analysis, we stratified results by recipient age (>50 or ≤50 y) at the time of retransplant.

Results.

Of 5594 repeat kidney transplants, 1397 (25.0%) developed DCGL. Overall, there was no association between first and second donor sex pairing and DCGL. A prior and current female donor (FD1FD2) posed a higher risk for DCGL in recipients aged >50 y at second transplant (hazard ratio,≤0.67, confidence interval 0.46-0.98, for all other donor combinations), but posed a lower risk if aged ≤50 y at retransplant (hazard ratio, ≥1.37, confidence interval 1.04-1.80, for all other donor combinations).

Conclusions.

Overall, past-current donor sex pairing was not associated with DCGL in female recipients undergoing second kidney transplant; however, the risk with a past and current female donor was increased in older, and decreased in younger, female recipients at retransplant.
Long-Term Outcomes of Mesohepatectomy for Centrally Located Liver Tumors: Two-Decade Single-Center Experience
Authors: Mehrabi Arianeb , Ramouz Ali , Golriz Mohammad , Khajeh Elias , Hackert Thilo , Müller-Stich Beat , Strobel Oliver , Hoffmann Katrin , Büchler Markus W ,   Liver Cancer Center Heidelberg (LCCH)
Published: July 2022

BACKGROUND:

Mesohepatectomy is a viable treatment option for patients diagnosed with centrally located liver tumors (CLLTs). There are several reports from Eastern centers, but few data are available on this topic from Western centers.

STUDY DESIGN:

Data of 128 consecutive patients who underwent mesohepatectomy between September 2000 and September 2020 in our center were analyzed from a prospectively collected database. Patient demographic data, liver tumor characteristics, and intraoperative data were collected. In addition, posthepatectomy bile leakage (PHBL), posthepatectomy hemorrhage (PHH), posthepatectomy liver failure (PHLF), and 90-day mortality after mesohepatectomy were assessed. Long-term outcomes were also reported, and factors that may influence disease-free survival were evaluated.

RESULTS:

Of 128 patients, 113 patients (88.3%) had malignant hepatic tumors (primary and metastatic tumors in 41 [32%] and 72 [56.3%] patients, respectively), and 15 patients suffered from benign lesions (11.7%). Among the relevant surgical complications (grade B or C), PHBL was the most common complication after mesohepatectomy and occurred in 11.7% of patients, followed by PHLF in 3.1% of patients and PHH in 2.3% of patients. Only four patients (3.1%) died within 90 days after mesohepatectomy. The 5-year overall survival and overall recurrence (for malignant lesion) rates were 76.5% and 45.1%, respectively.

CONCLUSION:

Mesohepatectomy is a safe and feasible surgical treatment with low morbidity and mortality for patients with CLLT. Long-term outcomes can be improved by increased surgical expertise.
Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework
Authors: Abel Mary Kathryn , Schwartz Hope , Lin Joseph A , Decker Hannah C , Wu Christopher L , Grant Michael C , Kushel Margot , Wick Elizabeth C
Published: July 2022

Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use.

Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.
Is Previous Postoperative Infection an Independent Risk Factor for Postoperative Infection after Second Unrelated Abdominal Operation?
Authors: Feldt Susan L , Keskey Robert , Krishnan Pranav , Hyman Neil H , Shogan Benjamin D
Published: July 2022

BACKGROUND:

Infections after abdominal surgery remain a significant problem. Although preoperative antibiotic prophylaxis is a primary strategy used to reduce postoperative infections, it is typically prescribed based on standardized protocols, without attention to previous infection or antibiotic history. Patients with a previous infection after surgery may be at higher risk for infectious complications after subsequent operations owing to antibiotic resistance. We hypothesized that a previous postoperative infection is a significant risk factor for the development of infection after a second unrelated surgery.

STUDY DESIGN:

We performed a retrospective study of patients who had undergone 2 unrelated abdominal operations at a tertiary care center from 2012 to 2018. Clinical variables and microbiological culture results were abstracted. Univariate and multivariable regression models were constructed.

RESULTS:

Of 758 patients, 15.0% (n = 114) developed an infection after the first operation. After the second operation, 22.8% (n = 26) of those with a previous infection developed another infection, whereas the incidence of an infection after the second operation was only 9.5% (n = 61) in patients who did not develop an infection after the first operation. Multivariable analysis demonstrated that previous infection (odds ratio 2.49, 95% CI 1.46 to 4.25) was associated with future infection risk. Microbiological analysis found that infections after the second surgery were significantly more likely to be antibiotic resistant than infections after the first surgery (82.3% vs 64.1%; p = 0.036). Strikingly, 49% of infections after the second surgery were resistant to the antibiotic prophylaxis given at the time of incision.

CONCLUSIONS:

Previous postoperative infection is an independent risk factor for a subsequent postoperative infection and is associated with resistance to standard prophylaxis. Individualization of antibiotic prophylaxis in patients with a previous postoperative infection is warranted.
Effect of Lymphaticovenous Anastomosis on Muscle Edema, Limb, and Subfascial Volume in Lower Limb Lymphedema: MRI Studies
Authors: Yang Johnson Chia-Shen , Wu Shao-Chun , Wang Yu-Ming , Luo Sheng-Dean , Kuo Spencer Chia-Hao , Chien Peng-Chen , Tsai Pei-Yu , Hsieh Ching-Hua , Lin Wei-Che
Published: July 2022

BACKGROUND:

Although satisfactory volume reduction in secondary unilateral lower limb lymphedema after lymphaticovenous anastomosis (LVA) in the affected limb has been well reported, alleviation of muscle edema and the impact of LVA on the contralateral limb have not been investigated.

STUDY DESIGN:

This retrospective cohort study enrolled patients who underwent supermicrosurgical LVA between November 2015 and January 2017. Pre- and post-LVA muscle edema were assessed using fractional anisotropy (FA) and apparent diffusion coefficient (ADC). The primary endpoint was changes in limb/subfascial volume assessed with magnetic resonance volumetry at least 6 months after LVA.

RESULTS:

Twenty-one patients were enrolled in this study. Significant percentage reductions in post-LVA muscle edema were found in the affected thigh (83.6% [interquartile range = range of Q1 to Q3; 29.8–137.1] [FA], 53.3% [27.0–78.4] [ADC]) as well as limb (21.7% [4.4–26.5]) and subfascial (18.7% [10.7–39.1]) volumes. Similar findings were noted in the affected lower leg: 71.8% [44.0–100.1] (FA), 59.1% [45.8–91.2] (ADC), 21.2% [6.8–38.2], and 28.2% [8.5–44.8], respectively (all p < 0.001). Significant alleviation of muscle edema was also evident in the contralateral limbs (thigh: 25.1% [20.4–57.5] [FA]; 10.7% [6.6–17.7] [ADC]; lower leg: 47.1% [35.0–62.8] [FA]; 14.6% [6.5–22.1] [ADC]; both p < 0.001), despite no statistically significant difference in limb and subfascial volumes.

CONCLUSIONS:

Our study found significant reductions in muscle edema and limb/subfascial volumes in the affected limb after LVA. Our findings regarding edema in the contralateral limb were consistent with possible lymphedema-associated systemic influence on the unaffected limb, which could be surgically relieved.
Early vs Delayed Surgery for Esophageal Cancer During the COVID-19 Pandemic
Authors: Bajaj Simar S , Shah Kavya M , Potter Alexandra L , Mayne Nicholas R , Sachdeva Uma M , Lin Mong-Wei , Yang Chi-Fu Jeffrey
Published: July 2022

BACKGROUND:

During the coronavirus disease 2019 pandemic, national guidelines recommended that elective surgery for esophageal cancer be deferred by 3 months when hospital resources are limited. The impact of this delay on patient outcomes is unknown. We sought to evaluate the survival of patients with stage I and II/III esophageal cancer who undergo early vs delayed treatment.

STUDY DESIGN:

Using the National Cancer Database from 2010 to 2017, multivariable Cox proportional hazards modeling and propensity score–matched analysis were employed to compare survival of patients with stage I esophageal cancer who received early (0 to 4 weeks after diagnosis) vs delayed esophagectomy (12 to 16 weeks) and of patients with stage II/III esophageal cancer who—after receiving timely chemoradiation (0 to 4 weeks after diagnosis)—underwent early (9 to 17 weeks) vs delayed esophagectomy (21 to 29 weeks).

RESULTS:

For stage I esophageal cancer, 226 (41.7%) patients underwent early esophagectomy, and 316 (58.3%) patients underwent delayed esophagectomy. Propensity score matching created 2 groups of 134 patients with early or delayed esophagectomy, whose 5-year survival was comparable (hazard ratio [HR] 65.0% [95% confidence interval (CI) 55.2% to 73.2%] vs HR 65.1% [95% CI 55.6% to 73.1%], p = 0.50). For stage II/III esophageal cancer, 1,236 (86.1%) patients underwent early esophagectomy, and 200 (13.9%) underwent delayed esophagectomy. Propensity score matching created 2 groups of 130 patients; the early esophagectomy group had improved 5-year survival compared with the delayed esophagectomy group (HR 41.6% [95% CI 32.1% to 50.8%] vs HR 22.9% [95% CI 14.9% to 31.8%], p = 0.006).

CONCLUSIONS:

Early esophagectomy was associated with similar survival compared with delayed esophagectomy for patients with stage I esophageal cancer. For patients with stage II/III esophageal cancer, early esophagectomy was associated with improved survival relative to delayed esophagectomy.
Well-Being Intervention in General Surgery: Multicenter Study of Program Director and Resident Perspectives
Authors: Greenberg Anya L , Tenzing Norbu , Ghadimi T Roxana , Tilahun Mekaleya N , Berler Michael H , Lebares Carter C ,   for the General Surgery Research Collaborative on Resident Well-Being
Published: July 2022

BACKGROUND:

Physician well-being is critical for optimal care, but rates of psychological distress among surgical trainees are rising. Although numerous efforts have been made, the perceived efficacy of well-being interventions is not well understood.

STUDY DESIGN:

This qualitative thematic study included online questionnaires to Program Directors (PDs) and residents at 16 ACGME-accredited General Surgery residency programs. PDs reported active well-being interventions for surgical residents or those under consideration at their institutions. Residents shared perspectives of available well-being interventions through open-ended responses. Conventional content analysis was used to analyze responses.

RESULTS:

Fifteen PDs, or their proxies (94% response rate), responded. Responses revealed that a majority of available well-being interventions are focused on changing the individual experience rather than the underlying workplace. PD decision-making around well-being interventions is often not based on objective data. Three hundred residents (34% response rate) responded. Of available interventions, those that increase control (eg advanced and flexible scheduling), increase support (eg mentorship), and decrease demand (eg work hour limits) were consistently identified as beneficial, but interventions perceived to increase demand (eg held during unprotected time) were consistently identified as not beneficial. Group social activities, cognitive skills training, and well-being committees were variably seen as beneficial (increasing support) or not (increasing demand).

CONCLUSIONS:

Our findings underscore the prevalence of individual-based well-being interventions and the paucity of system-level changes. This may explain, in part, the persistence of distress among residents despite abundant effort, highlighting the imperative for system-level transformation.
Optimizing Perioperative Venous Thromboembolism Chemoprophylaxis on a Gynecologic Oncology Service
Authors: Lippitt Melissa H , Johnson Emily S , Frost Anja S , Thompson Sharon D , Kashi Payam K , Beavis Anna L , Fader Amanda N , Ferriss J Stuart , Stone Rebecca L , Wethington Stephanie L
Published: July 2022

BACKGROUND:

Perioperative venous thromboembolism (VTE) is a significant cause of morbidity and mortality after gynecologic cancer surgery. Here we report a quality improvement intervention to increase perioperative VTE chemoprophylaxis compliance.

STUDY DESIGN:

All operations performed by a gynecologic oncologist at a tertiary urban university medical center admitted to the hospital for at least one midnight were included. Using a pre/post design with a washout period, we sought to increase perioperative VTE chemoprophylaxis compliance from 22% in the historical control (HC) cohort to 90% in the quality improvement (QI) cohort. The perioperative VTE chemoprophylaxis process was standardized by addressing four domains: preoperative VTE chemoprophylaxis, surgical time-out, postoperative VTE chemoprophylaxis, and intervention education and compliance tracking. Pearson’s chi-square test was used to compare HC vs QI cohort compliance.

RESULTS:

There were 130 surgical cases in the HC cohort and 131 in the QI cohort. Forty-two percent underwent laparotomy, and 57% had cancer at the time of operation. VTE chemoprophylaxis compliance improved from 22% in the HC cohort to 82% in the QI cohort (p < 0.001). Preoperative VTE chemoprophylaxis compliance improved from 76% in the HC cohort to 94% in the QI cohort (p < 0.001), and postoperative VTE chemoprophylaxis compliance improved from 27% to 87% (p < 0.001). Thirty-day postoperative VTE occurred in three patients (2%) in the HC cohort and none in the QI cohort (p = 0.08).

CONCLUSIONS:

A low-cost and low-technology QI initiative intervention improved perioperative compliance with VTE chemoprophylaxis.
Minimally Invasive vs Open Pancreatectomy for Pancreatic Neuroendocrine Tumors: Multi-Institutional 10-Year Experience of 1,023 Patients
Authors: Zheng Jian , Pulvirenti Alessandra , Javed Ammar A , Michelakos Theodoros , Paniccia Alessandro , Lee Kenneth K , Ferrone Cristina R , Wei Alice C , He Jin , Zureikat Amer H ,   additional members of the Pancreatic Neuroendocrine Disease Alliance (PANDA)
Published: July 2022

BACKGROUND:

Resection of pancreatic neuroendocrine tumors (PNETs) may be associated with adverse perioperative outcomes compared with pancreatic adenocarcinoma given the high-risk nature of soft glands with small pancreatic ducts. The effect of minimally invasive surgery (MIS) pancreatectomy on outcomes of PNETs remains to be examined, which is the aim of this study.

STUDY DESIGN:

Between 2009 and 2019, 1,023 patients underwent pancreatectomy for PNETs at 4 institutions. Clinicopathologic data and perioperative outcomes of patients who underwent MIS (n = 447) and open resections (n = 576) were compared.

RESULTS:

Of the 1,023 patients, 51% were male, the mean age was 58, the median tumor size was 2.1 cm, and 73% were grade 1 PNETs. There were 318 (31%) pancreatoduodenectomies (PDs), 541 (53%) distal pancreatectomies (DPs), 80 (7.8%) enucleation (ENs), 72 (7%) central pancreatectomies (CPs), and 12 (1.2%) total pancreatectomies. Almost half of the patients (N = 447, 44%) had MIS operations, of which 230 (51%) were robotic and 217 (49%) were laparoscopic. Compared with open operations, MIS PDs had significantly lower operative blood loss (150 vs 400 mL, p < 0.001) and rate of clinically relevant postoperative pancreatic fistulas (CR-POPFs; 13% vs 27%, p = 0.030), and MIS DPs had a shorter length of stay (5 vs 6 days, p < 0.001). Although MIS DPs and ENs had CR-POPFs comparable with open operations, MIS CPs had a higher CR-POPF rate (45% vs 15%, p = 0.013). After adjusting for pathological differences, MIS pancreatectomy was associated with recurrence-free survival and overall survival comparable with open pancreatectomy.

CONCLUSIONS:

MIS pancreatectomy for PNETs is associated with improved outcomes or outcomes comparable with open resection.
BA.4/BA.5 early surge report Austria
Authors: Gamisch Alexander , Mustafa Maria Elisabeth
Published: July 2022

More than two years into the COVID-19 pandemic, the emergence of the Omicron subvariants BA.4 and BA.5 initiated the fifth wave. BA.4/BA.5 share identical spike proteins and are thus difficult to differentiate using standard diagnostic tests. The true frequency and diversity of the two variants in Austria is therefore largely unknown. Aim of this report is to take stock about the frequency and diversity of BA.4 & BA.5 and their subvariants based on whole genome sequencing (WGS) data as deposited at GISAID database. Results show that most sequenced cases belong to BA.5 (c. 86 %) rather than BA.4 (c. 14 %) and that most of the global diversity (24 out of 32 subvariants) of BA.4 and BA.5 in terms of subvariants described is already present in Austria. However, most cases can be attributed to a few subvariants (e.g. BA.5.1, BE.1.1, BA.5.3, BA.5.2.1) with high estimated growth advantage over BA.2 (ranging 103 to 159 %) and may be worth monitoring as the immediate wave unfolds.
The Relation Between Viscous Energy Dissipation And Pulsation For Aortic Hemodynamics Driven By A Left Ventricular Assist Device
Authors: Sahni Akshita , McIntyre Erin E. , Cao Kelly , Pal Jay D. , Mukherjee Debanjan
Published: July 2022

Left ventricular assist device (LVAD) provides mechanical circulatory support for patients with advanced heart failure. Treatment using LVAD is commonly associated with complications such as stroke and gastro-intestinal bleeding. These complications are intimately related to the state of hemodynamics in the aorta, driven by a jet flow from the LVAD outflow graft that impinges into the aorta wall. Here we conduct a systematic analyses of hemodynamics driven by an LVAD with a specific focus on viscous energy transport and dissipation. We conduct a complementary set of analysis using idealized cylindrical tubes with diameter equivalent to common carotid artery and aorta, and a patient-specific model of 27 different LVAD configurations. Results from our analysis demonstrate how energy dissipation is governed by key parameters such as frequency and pulsation, wall elasticity, and LVAD outflow graft surgical anastomosis. We find that frequency, pulsation, and surgical angles have a dominant effect, while wall elasticity has a weaker effect, in determining the state of energy dissipation. For the patient-specific scenario, we also find that energy dissipation is higher in the aortic arch and lower in the abdominal aorta, when compared to the baseline flow without an LVAD. This further illustrates the key hemodynamic role played by the LVAD outflow jet impingement, and subsequent aortic hemodynamics during LVAD operation.