General Surgery Specialties Research Articles

Technological implementation in General Surgery services in Spain. National survey and results

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard.From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

1448Intensive care utilisation in New Zealand 2010 to 2020

BackgroundMany countries are assessing their capacity of intensive care (IC) after COVID-19 outbreak due to massively increase in the utilisation. This work analysed the utilisation of IC in New Zealand (NZ) between 2010 and 2020, as a base to predict and plan the health service in the future.MethodsInpatient events from NZ national data collection and datasets from the Australian and New Zealand Intensive Care Society were matched to generate a relatively comprehensive IC dataset for patients cared in NZ.ResultsOver the period, around 182,000 IC inpatient events with associated 12.1 million IC hours were identified. For NZ patients, age-standardised rate was 328 events or 905 IC bed days per 100,000 population. The age-standardised rates were significantly higher in Maori and Pacific, and significantly lower in Asian population. The absolute IC events and IC hours significantly increased over the period, with a slope of 390 IC events or 29,000 IC hours per year. Significant increase in IC hours over the period were found in the diagnostic categories of injuries, cardiovascular diseases, neurological conditions and lower respiratory infections; or patients cared by health specialties of cardiothoracic surgery, general surgery, orthopaedic surgery and respiratory medicine.ConclusionsThe IC utilisation are different in population subgroups. Trends and volumes of IC utilisation in different clinical diagnoses and health specialties were quantified.Key messagesWith population projection, these results provide evidence to predict IC capacity demand and to design IC services (e.g. health specialties, IC beds and investment needed) in the future.

Hospital Antibiotic Prescribing Pattern in General Surgery Specialty: Analysis Based on the WHO Access, Watch and Reserve (AWaRe) Classification

Background: Surgical site infections are a prevalent cause of nosocomial infections that require antibiotic prophylaxis. Emergence and spread of antimicrobial resistance is a major global public health issue that must be addressed. Eventually, antibiotic prescribing pattern should be examined in order to ensure that antibiotics are used appropriately and that their effectiveness is preserved.
 Objective: To evaluate hospital antibiotic prescribing pattern emphasizing on cephalosporins in general surgery specialty using the WHO Access, Watch, and Reserve (AWaRe) classification.
 Methodology: A cross-sectional study was carried out in 658 hospitalized patients who received prophylactic antibiotics in general surgery specialty for six months. The data were analysed using the ‘WHO prescribing indicators’ and examined for the WHO ‘AWaRe’ categories. The acquired data was subjected to descriptive statistics.
 Results: Per encounter, the average number of drugs and antibiotics prescribed were 3.8 and 1.3, respectively. 83.4% encounters were with at least one antibiotic and 94.5% encounters had parenteral antibiotics. 31.3% and 77.8% antibiotics were prescribed by generic name and from the Essential Medicines List, respectively. The most frequently prescribed antibiotics were the third generation cephalosporins (36.8%) wherein ceftriaxone (22.0%) and cefoperazone (7.2%) were the two most commonly prescribed. A total of 14 specific antibiotics, ‘Access’ 5 and ‘Watch’ 9 were prescribed. Based on the WHO AWaRe classification, 42.3% ‘Access’ and 57.7% ‘Watch’ group antibiotics prescribed. All the prescribed cephalosporins (100%) were from the ‘Watch’ category. Amikacin (13.5%) and ceftriaxone (22.0%) were the most commonly prescribed ‘Access’ and ‘Watch’ group antibiotics, respectively. Amoxicillin index was 7.5 and ‘Access-to-Watch’ index was 0.7, which were much below the priority values.
 Conclusion: The antibiotic prescription pattern seen in this study did not entirely meet the WHO recommendations. Antibiotics from the ‘Watch’ category, notably cephalosporins, were commonly prescribed. To retain antibiotic effectiveness and encourage rational antibiotic use, as well as to overcome antibiotic resistance, changes and surveillance antibiotics prescribing are required.

Impact of the COVID-19 pandemic on surgical trainee education and well-being spring 2020-winter 2020: A path forward

BackgroundThe time course and longitudinal impact of the COVID -19 pandemic on surgical education(SE) and learner well-being (LWB)is unknown. Material and methodsCheck-in surveys were distributed to Surgery Program Directors and Department Chairs, including general surgery and surgical specialties, in the summer and winter of 2020 and compared to a survey from spring 2020. Statistical associations for items with self-reported ACGME Stage and the survey period were assessed using categorical analysis. ResultsStage 3 institutions were reported in spring (30%), summer (4%) [p < 0.0001] and increased in the winter (18%). Severe disruption (SD) was stage dependent (Stage 3; 45% (83/184) vs. Stages 1 and 2; 26% (206/801)[p < 0.0001]). This lessened in the winter (23%) vs. spring (32%) p = 0.02. LWB severe disruption was similar in spring 27%, summer 22%, winter 25% and was associated with Stage 3. ConclusionsSteps taken during the pandemic reduced SD but did not improve LWB. Systemic efforts are needed to protect learners and combat isolation pervasive in a pandemic.

“It Will Work”: The Story of Nina Starr Braunwald and the First Successful Mitral Valve Replacement

Cardiothoracic surgery is a clinical and scientific discipline that has evolved enormously over the last decades. Cardiac problems that were historically death sentences can now be addressed with approaches that only continue to improve. In the late 1950s, while cardiothoracic surgery was still a nascent field, Nina Starr Braunwald emerged as a pioneer for this exponential improvement. As the first woman cardiac surgeon in an era in which general surgery and surgical specialties were dominated by men, Dr Braunwald not only made revolutionary contributions to cardiothoracic surgery, but also did so while balancing roles as a dedicated mother and supportive partner.

Enhanced recovery after emergency surgery: Utopia or reality?

Enhanced recovery after surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

Implementación tecnológica en los servicios de Cirugía General y del Aparato Digestivo en España. Encuesta nacional y resultados

Technology is one of the pillars of surgery in the 21st century and is a key factor in achieving better surgical results. The current surgical process involves not only surgical techniques, but also a very high degree of specialisation and the knowledge and use of techniques and devices from other fields. In Spain, there are no studies published at a national level in this regard.From the Minimally Invasive Surgery and Technological Innovation section of the Spanish Association of Surgeons we have designed a study whose main objective is to evaluate the degree of technological implantation in the specialty of General Surgery in Spain, as well as to analyze the devices available in the different centres of the country. We propose to make a detailed description of the applications of these devices and techniques by areas of interest, pointing out the pathologies and procedures in which this technology is used.

Soran Akram Agha Chawishly

Soran Akram Agha Chawishly was born on 4 January 1951 in Erbil, Iraq, to Akram and Rasmieh Chawishly, their second son and one of six children. After completing his primary...

Sexual activity and contraceptive use during social distancing and self-isolation in the COVID-19 pandemic

Objectives The aims of the study were to investigate the effects of social distancing during the COVID-19 pandemic on the use of hormonal contraceptives, their discontinuation and the risk of unplanned pregnancy. Methods The study enrolled 317 women listed in the database of the Department of General Surgery and Medical-Surgical Specialties, University of Catania, Italy, family planning clinic who were known to be using hormonal contraceptives. The women were contacted by telephone and asked whether they would like to participate in the study. If they agreed, they were then emailed a questionnaire about their social behaviour and sexual activity during the pandemic, according to their cohabiting status, i.e., whether they were continuing to use their hormonal contraception and whether they had had an unplanned pregnancy. Results The questionnaire was completed by 175 (81.8%) women who were using short-acting reversible contraception (SARC) and by 90 (87.4%) women who were using long-acting reversible contraception (LARC). All married and cohabiting women were continuing to use their contraceptive method. None had had an unplanned pregnancy. On the other hand, 51 (50.5%) non-cohabiting or single women had discontinued their SARC method while social distancing, for non-method-related reasons; however, 47 (46.5%) non-cohabiting or single women had continued their sexual activity, infringing social distancing rules, and 14.9% had had an unplanned pregnancy, for which they had sought a termination. Conclusion Several non-cohabiting women using SARC had discontinued their contraceptive method during the pandemic but had continued to engage in sexual activity and had had an unplanned pregnancy. Clinicians should counsel women about what they should do in regard to contraception in the event of new, future social distancing measures.

Impact of the COVID-19 Pandemic on Surgical Training and Learner Well-Being: Report of a Survey of General Surgery and Other Surgical Specialty Educators

BackgroundThe COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication was to report the impact of the pandemic on surgical training and learner well-being and to document adaptations made by surgery departments.Study DesignA 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic, as defined by the ACGME. Statistical associations for items with stage were assessed using categorical analysis.ResultsThe response rate was 21% (472 of 2,196). US stage distribution (n = 447) was as follows: stage 1, 22%; stage 2, 48%; and stage 3, 30%. Impact on clinical education significantly increased by stage, with severe reductions in nonemergency operations (73% and 86% vs 98%) and emergency operations (8% and 16% vs 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7% and 13% vs 37%). Severity of impact on didactic education increased with stage (14% and 30% vs 46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner well-being increased by stage—physical safety (6% and 9% vs 31%), physical health (0% and 7% vs 17%), and emotional health (11% and 24% vs 42%). Regardless of stage, most but not all made adaptations to support trainees’ well-being.ConclusionsThe pandemic adversely impacted surgical training and the well-being of learners across all surgical specialties proportional to increasing ACGME stage. There is a need to develop education disaster plans to support technical competency and learner well-being. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have a considerable impact on the future of surgical education.

Residency Specialty and National Resident Matching Program Outcomes as Predictors of Academic vs Non-Academic Position as an Attending Physician.

Purpose: Previous studies have shown that research can be used as a predictive factor for an academic career for physicians in the fields of radiation oncology, orthopedic surgery, and diagnostic radiology. We seek to determine if this factor is predictive for all medical specialties based on an analysis of public data on physicians who have trained at Hershey Medical Center (HMC) and public National Resident Matching Program (NRMP) charting outcomes.Methods: We determined the location and job title of all graduates of HMC residency training programs through a combination of publicly available information on HMC's website and other institutions' websites. We separated these into academic and non-academic positions and performed Chi-square analysis to determine if the number of research experiences was predictive of an academic career.Results: Participating in the residency specialties of general surgery, pathology, internal medicine, and neurological surgery are statistically significant predictors of an academic career upon graduation. The average number of research experiences obtained by matched U.S. medical students is not a statistically significant predictor of an academic career upon graduation.Conclusion: In contrast to previously published studies, a higher number of research experiences in medical school is not a significant predictor of an academic career for attending physicians who graduated residency at HMC.

Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning

BackgroundCodeine and tramadol are commonly used analgesics in surgery. In 2013, the Food and Drug Administration (FDA) issued a contraindication to the use of codeine in tonsillectomy and adenoidectomy patients aged below 18 y. This warning was expanded in April 2017 to include tramadol and all children aged below 12 y. We sought to describe the prescribing of codeine and tramadol to contraindicated populations in Wisconsin before and after the release of the expanded FDA warning. Materials and methodsUsing a statewide Wisconsin claims database, we identified common pediatric ambulatory surgical procedures across the specialties of otolaryngology, urology, general surgery, orthopedics, and ophthalmology. For these procedures, we examined the rates of perioperative codeine and tramadol prescription fills and change in prescribing after the FDA contraindication. ResultsSurgeons in all of the specialties studied continued to prescribe codeine to pediatric patients after the contraindication, but tramadol was rarely prescribed. Procedures with relatively high rates of codeine fills were strabismus repair (65% of opioid fills), circumcision >1 yo (22%), and laparoscopic appendectomy (15%). Codeine fills significantly declined after the contraindication to 6% for circumcision >1 yo and 5% for orchiopexy and inguinal hernia repair. Otolaryngology, which was subject to the 2013 codeine contraindication, has low rates of codeine fills (under 2.5%) for the whole period studied. Codeine prescribing for strabismus repair showed no significant decline. ConclusionsCodeine, and to a lesser extent tramadol, continue to be prescribed to contraindicated populations of children. This represents a target for future de-implementation interventions.

Thoracic Surgery Preparation, Patient Election, and Its Management During Covid-19 Pandemic: Surabaya Experiences

A novel coronavirus pneumonia outbreak began in Wuhan, Hubei Province, in December 2019. It has spread rapidly from China to worldwide. The COVID-19 pandemic of 2020 posed a historic challenge to health care systems around the world, healthcare systems needed to consider providing clinical services to other patients in need. The specialty of general thoracic surgery includes the management of serious diseases such as chest wall congenital anomaly, lung cancers, esophageal cancers, mediastinal tumor, chest wall infection, and trauma. Thoracic surgery is one of high risk procedure in this pandemic, however, a high level of evidence supports the surgical management of potential patients with thoracic disease and anomaly is still lacking. Critical determinants of robust thoracic surgery service provision are pre-existing plans for epidemic response. "Flatten the curve" as an aggressive action is needed. Prioritizations of thoracic surgery cases are needed to differ between elective and emergency cases to limit any contamination. Before surgery, important pre-operative assessments were conducted aims to identify patients' high risk and adjust the procedure. example of a recommendation, if urgent / emergency surgery with symptoms clear clinical pneumonia or rapid test (+). The lessons learned can apply to the other areas during this pandemic, and the world, in preparation for the next one.

Implementation of General Surgery Care into a Student-Run Free Clinic

BackgroundStudent-run free clinics (SRFCs) provide medical care to uninsured, and surgical issues are often outside the normal scope of care of these clinics. The Shade Tree Clinic (STC) is an SRFC serving 300 patients with complex medical conditions. This study describes the implementation and efficacy of a General Surgery Specialty Clinic in this setting. MethodsThis descriptive study examines the demographics and referral patterns of patients seen in two pilot Specialty Clinics and other patients evaluated for general surgical issues from December 2017 to January 2020. Providers were surveyed regarding their experience in clinic. ResultsTwenty patients were evaluated by six general surgeons during 22 separate encounters (n = 20). Nine patients were seen in two pilot Specialty Clinics for biliary colic, hernia, hemorrhoids, anal mass, toenail lesion, surgical weight loss, and venous insufficiency. Referrals from these clinics to affiliated Vanderbilt University Medical Center included six ultrasounds; referrals to vascular surgery and podiatry clinics; and referrals for laparoscopic cholecystectomy and anal mass excision. STC also directly referred eight patients for colonoscopies and five patients for major operations through primary care clinic. Hundred percent of care was cost-free to patients. Providers reported a median satisfaction score of five with the Specialty Clinics (Very Satisfied; [4, 5]). Hundred percent of providers felt that the concerns of patients were addressed. ConclusionsA surgery specialty clinic in the setting of an SRFC is an effective way to provide surgical care to underserved populations with the potential to reduce unplanned hospital utilization.

Factors attributable to the cancellation of programmed surgeries.

To analyze the factors attributable to the cancellation of surgeries of a third level health institution in the city of Valledupar, Cesar / Colombia (2017-2018). Descriptive, retrospective, cross-sectional study. Data from the hospital surgical unit adverse case file were collected for 6 surgical specialties. They showed that in 2017 there was a surgical suspension of 4% of the total of scheduled surgeries that were (3339), for 2018 the rate was 3% with a total of scheduled surgeries (1733). The reason for the suspension for both periods was the factor related to the patient's adverse conditions with 45.9 and 38.5% respectively. The specialty most affected for these cases was the specialty of general surgery with the same percentage value in both periods of 4%. The results give us an idea of the factors present for the cancellation of scheduled surgeries and the need to apply measures to guarantee patient safety.

Rehabilitación multimodal en cirugía de urgencias: ¿utopía o realidad?

Enhanced Recovery After Surgery (ERAS) constitutes the application of a series of perioperative measures based on the evidence, in order to achieve a better recovery of the patient and a decrease of the complications and the mortality. These ERAS programs initially proved their advantages in the field of colorectal surgery being progressively adopted by other surgical areas within the general surgery and other surgical specialties. The main excluding factor for the application of such programs has been the urgent clinical presentation, which has caused that despite the large volume of existing literature on ERAS in elective surgery, there are few studies that have investigated the effectiveness of these programs in surgical patients in emergencies. The aim of this article is to show ERAS measures currently available according to the existing evidence for emergency surgery.

P146: Workplace bullying and harassment among specialty registrars in London - A questionnaire survey highlighting a priority issue

Introduction: Bullying within the NHS costs billions and impacts on patient safety, quality of care and patient satisfaction. Although bullying is anecdotally widespread, to date the experience amongst general surgery specialty trainees has not been fully evaluated in London. The purpose of this study was to determine the prevalence amongst London trainees and evaluate the impact on their career.

The translation of surgical animal models to human clinical research: A cross-sectional study.

Surgical animal models are used in pre-clinical scientific studies. To date there has not been an analysis of how effective these data are when translated to human/clinical research. In this retrospective review, we evaluate the impact of studies using surgical animal models on human/clinical research through study-level analysis of citations. The top two ranking clinical journals based on impact factor for the top ten surgical specialties were identified and a search was run on PubMed to identify studies using surgical animal models published in the years 2007 and 2008. The translation to human/clinical research of each study was evaluated by analyzing the frequency of citation in human studies over the ten years following publication. Regression was used to identify predictors of citation in human/clinical research. 411 animal studies using surgical models were identified. Over the course of the 10 years following publication the original animal studies were cited 6063 times, with 1300 (21.4%) citations in human/clinical studies and 4763 (78.6%) in animal/basic science studies. The median number of citations in human/clinical research was 1 (IQR 0-5). Regression showed an association between citation in human/clinical research and the use of porcine models and the specialties of general surgery, oral and maxillofacial surgery, orthopedic surgery, transplant, and plastic surgery. The use of animal models in surgical research shows poor translation to human/clinical research. Alternative surgical models should urgently be explored.

General anesthesia is predictive for occurrence of postoperative pain

ABSTRACT BACKGROUND AND OBJECTIVES: Pain is one of the most frequent complications in the post- anesthetic care unit. Knowing the risk variables is one strategy for its prevention. The objective of the present study was to identify the predictive variables for pain in the post anesthetic care unit, regardless of its intensity. METHODS: This was an observational and cross-sectional study with primary data with 98 adults submitted to elective surgery. The pain was assessed using a numerical scale. The patients were divided into two groups: the presence or absence of pain. Also, pre, intra, and postoperative information were gathered. Descriptive, comparative analysis between groups and logistic regression were conducted. RESULTS: Pain in the post anesthetic care unit was mentioned by 34.7% of the sample, classified as severe by the majority (61.8%). A significant statistical relationship was found between the presence of pain, regardless of intensity, and two preoperative variables, nine intraoperative variables, and four postoperative variables, namely: female sex; general surgery specialty; supine position; general anesthesia; greater use of intravenous opioids and lower use of intrathecal morphine in the intraoperative period; time in surgery greater than 120 minutes; and oxygen desaturation in the postoperative period. The regression analysis revealed that general anesthesia increased the probability of pain in the post anesthetic care unit by 9.5 times. CONCLUSION: General anesthesia was identified as predictive of pain in the post-anesthetic care unit, indicating the profile of patients at higher risk.

Effective use of CT by surgeons in acute appendicitis diagnosis.

Acute appendicitis (AA) still maintains its prominence among general surgical emergencies, and the risk of developing AA is 8.6% for men and 6.7% for women. The clinical diagnosis of acute appendicitis has a rate of approximately 20% false positive and false-negative. Ultrasound (US) and Computed Tomography (CT) are the imaging methods most utilized in this field. The present study aims to determine the relationship between the evaluation results of the clinician who examined the patient and the radiologist's evaluation in the evaluation of cross-sectional imaging tests for the diagnosis of acute appendicitis. In this study, the records of 1891 patients who underwent an appendectomy in the General Surgery Clinic of Fatih Sultan Mehmet Training and Research Hospital between January 2010 and 2017 were reviewed retrospectively. From the file of the patients who underwent appendectomy with acute appendicitis and whose appendix was reported as normal in CT results, clinical examination findings of the patient in the emergency department and CT evaluation results of the relevant surgeon (Compatible with acute appendicitis, normal appendix or appendix could not be visualised) were recorded. Of the 1891 patients, who underwent appendectomy on suspicion of acute appendicitis, 1478 had CT scans for diagnosis and 145 were reported as normal by radiologists. In the evaluations by surgeons of these CT results all reported as normal by radiologists, 105 (%) 72,4) were compatible with acute appendicitis, while 18 (12.4%) were considered normal. In 22 (15.2%) patients, appendix could not be the visualized by surgeons. 70.0% of the cases with Lymphoid hyperplasia - fibrous obliteration pathology result; 73.8% of the cases with acute appendicitis; 75.6% of those with phlegmonousappendicitis and 64.0% of those with gangrenous/perforated appendicitis were diagnosed as appendicitis by CT evaluation performed by a general surgeon. Diagnostic accuracy rates increase significantly when the CT results are interpreted by the physician performing the clinical evaluation of the patient. The chance of reaching the correct diagnosis will increase with gaining the ability to interpret abdominal cross-sectional imaging techniques during general surgery specialty training.