General Surgical Research Articles

Current state of minimally invasive general surgical practice in Africa: A systematic review and meta-analysis of the laparoscopic procedures performed and outcomes.

Minimally invasive surgery, including laparoscopy and robotics, has significantly improved general surgical (GS) practice globally. While robot-assisted GS practice is yet to be adopted in the majority of Africa, laparoscopy has been utilized to improve surgical outcomes. This study aims to review the laparoscopic GS procedures (LGSPs) performed and evaluate outcomes such as conversion to open surgery, morbidity, and mortality in Africa. Four databases (PubMed, Google Scholar, WoS, and AJOL) were searched, identifying 8022 publications. Following screening, 40 studies across Africa that reported LGSPs (n≥2) performed and outcomes met the inclusion criteria. A meta-analysis conducted using R statistical software estimated the pooled prevalences with the 95% CI of conversion, morbidity, and mortality. A total of 6381 procedures performed in 15 African countries were analyzed in this study. Majority, 72.89%, of the procedures were performed in Senegal, South Africa, and Nigeria. The major procedures performed were cholecystectomy (37.09%), appendicectomy (33.36%), and diagnostic laparoscopy (9.98%). The meta-analysis revealed a conversion rate of 5% [95% CI: 4, 7]. Adhesion (28.13%), hemorrhage (16.67%), technical difficultly (12.50%), and equipment failure (11.46%) were the predominant indications for conversion. Surgical site infection (42.75%) was the major cause of morbidity. The prevalences of morbidity and mortality were 7% [95% CI: 5, 10] and 0.12% [95% CI: 0, 0.29], respectively. A wide range of basic and advanced LGSPs were performed. The outcomes obtained indicate successful implementation of the laparoscopic approach. Importantly, this study serves as a foundational work for further research on minimally invasive surgery in Africa.

Agreement and Intraobserver Variability in Detection of Helicobacter pylori Infection Using Routine Histology, H. pylori Immunohistochemical Stain, and Warthin-Starry Special Stain on Gastric Tissue Biopsy Samples

Abstract Introduction/Objective Helicobacter pylori (HP) is a prevalent cause of gastritis in the US and worldwide. Accurate detection of the organism is important for appropriate treatment. Diagnosis is made using immunohistochemistry and special stains including Warthin-Starry stain (WS) which is low cost, technically easy to perform on tissue sections, and can be automated. We aimed to assess interobserver variability, reproducibility and validity of hematoxylin and eosin stain (H&E), WS and anti-Helicobacter pylori immunohistochemical staining (HP-IHC) for the histopathological identification and evaluation of HP organisms on gastric mucosa biopsies. Methods/Case Report We prospectively evaluated gastric biopsies from ten adult patients. These patients underwent upper gastrointestinal endoscopy with subsequent biopsy for various abdominal complaints. Seven of the ten biopsies (7/10) were HP infection positive, and three cases (3/10) were HP negative by H&E stain and HP-IHC (determined by GI Pathologist). The presence or absence and density of HP, were assessed on H&E, HP-IHC and WS in blinded fashion by five general surgical (GS) pathologists. The GS pathologists assessed the cases for presence and density of HP using the semi-quantitative modified Sydney classification (none, mild, moderate, and severe). Percentage agreement and interobserver variablilty using Cohen-Kappas statistics (KS) were calculated. Results (if a Case Study enter NA) The percentage agreement for presence or absence of HP in the biopsies with H&E, HP-IHC and WS stains were 91%, 98% and 99%, respectively. The interobserver agreement for evaluation of presence of HP was excellent with WS staining method (Overall KS = 0.737 95%, Confidence Interval (CI) = 0.501- 0.973) and HP-IHC (Overall KS = 0.783, 95% CI = 0.585-0.980). Agreement for H&E was moderate (Overall KS = 0.532, 95% CI= 0.392-0.672). HP density agreement was excellent using WS and HP-IHC and H&E was in the moderate range. Conclusion This study found excellent interobserver agreement using IHC and WS. While IHC is the most specific stain, WS is more sensitive in identifying the shape and morphology of HP organisms and is an efficient and low-cost alternative with excellent morphology in general surgical practice.

The characteristics and outcomes of trauma admissions to an adult general surgery ward in a tertiary teaching hospital.

BackgroundTraumatic injuries are proportionally higher in low- and middle-income countries (LMICs) than high-income counties. Data on trauma epidemiology and patients' outcomes are limited in LMICs.MethodsA retrospective review of medical records was performed for trauma admissions to the Princess Marina Hospital general surgical (GS) wards from August 2017 to July 2018. Data on demographics, mechanisms of injury, body parts injured, Revised Trauma Score, surgical procedures, hospital stay, and outcomes were analysed.ResultsDuring the study period, 2610 patients were admitted to GS wards, 1307 were emergency admissions. Trauma contributed 22.1% (576) of the total and 44.1% of the emergency admissions. Among the trauma admissions, 79.3% (457) were male. The median[interquartile range(IQR)](range) age in years was 30[24–40](13–97). The main mechanisms of injury were interpersonal violence (IPV), 53.1% and road traffic crashes (RTCs), 23.1%. More females than males suffered animal bites (5.9% vs. 0.9%), and burns (8.4% vs. 4.2%), while more males than females were affected by IPV (57.8% vs. 35.3%) and self-harm (5.5% vs. 3.4%). Multiple body parts were injured in 6.6%, mainly by RTCs. Interpersonal violence (IPV) and RTCs resulted in significant numbers of head and neck injuries, 57.3% and 22.2% respectively. More females than males had multiple body-parts injury 34.5% vs. 18.5%. Revised Trauma Score (RTS) of ≤11 was recorded in IPV, 38.4% and RTCs, 33.6%. Surgical procedures were performed on 44.4% patients. The most common surgical procedures were laparotomy (27.8%), insertion of chest tube (27.8%), and craniotomy/burr hole(25.1%). Complications were recorded in 10.1% of the patients(58) including 39 deaths, 6.8% of the 576.ConclusionTrauma contributed significantly to the total GS and emergency admissions. The most common mechanism of injury was IPV with head and neck the most frequently injured body part. Further studies on IPV and trauma admissions involving paediatric and orthopaedic patients are warranted.

Development of an enhanced acute care surgery service in response to the COVID-19 global pandemic

BackgroundAs the COVID-19 pandemic sweeps across the world, healthcare departments must adapt to meet the challenges of service provision and staff/patient protection. Unlike elective surgery, acute care surgery (ACS) workloads cannot be artificially reduced providing a unique challenge for administrators to balance healthcare resources between the COVID-19 surge and regular patient admissions. MethodsAn enhanced ACS (eACS) model of care is described with the aim of limiting COVID-19 healthcare worker and patient cross-infection as well as providing 24/7 management of emergency general surgical (GS) and trauma patients. The eACS service comprised 5 independent teams covering a rolling 1:5 24-hr call. Attempts to completely separate eACS teams and patients from the elective side were made. The service was compared to the existing ACS service in terms of clinical and efficiency outcomes. Finally, a survey of staff attitudes towards these changes, concerns regarding COVID-19 and psychological well-being was assessed. ResultsThere were no staff/patient COVID-19 cross-infections. Compared to the ACS service, eACS patients had reduced overall length of stay (2-days), time spent in the Emergency Room (46 min) and time from surgery to discharge (2.4-hours). The eACS model of care saved financial resources and bed-days for the organisation. The changes were well received by team-members who also felt that their safety was prioritised. ConclusionIn healthcare systems not overwhelmed by COVID-19, an eACS model may assist in preserving psychological well-being for healthcare staff whilst providing 24/7 care for emergency GS and trauma patients.

The Process of Implementing a Mobility Technician in the General Medicine and Surgical Population to Increase Patient Mobility and Improve Hospital Quality Measures: A Pilot Study

Background: Hospital-associated disability (HAD) has been linked to prolonged and inappropriate immobility. HAD and increased postacute care (PAC) rehabilitation spending are also associated. Purpose: This pilot aims to describe the implementation processes of a designated mobility technician (MT), providing daily mobility on a medical and surgical acute care unit. During the MT implementation, we explore the resulting effects on patient length of stay (LOS), PAC utilization, patient satisfaction, falls, and hospital cost. Methods: A quality improvement pilot study was created comparing the percentage of PAC discharge locations before and during the mobility pilot (MP) on 1 general medical (GM) unit (37 beds) and 1 general surgical (GS) unit (27 beds). Following the nursing assessment of medical stability and mobility with a progressive mobility algorithm, patients were assigned a Johns Hopkins Highest Level of Mobility (JH-HLM) score and placed on the MT schedule. The MT mobilized each selected patient to the next appropriate level of mobility, with a goal of at least 1 JH-HLM level of increase and recorded the score. Patient discharge location was recorded at the end of the inpatient stay. Patient satisfaction scores, LOS, and incidence of falls were also monitored throughout the pilot. Outcomes: Eighty-nine percent of GM compared with 83% of the baseline data group patients and 83% of the GS compared with 90% for the baseline data group patients discharged to home with an average increase in JH-HLM score of 1.22 per mobility session. In addition, during the MP both units decreased the LOS by 5.84% to 9.03%, the GS unit experienced increased patient satisfaction scores by 9.19%, and both units improved Press Ganey ratings of Responsiveness of Staff by 16.47% to 37.00%. No falls were associated with the MT or MP and the GM unit decreased overall falls by 53.3%. Discussion: The MP is a promising tool for increasing patient mobility in the nonintensive care GM and GS setting, while potentially decreasing the need for PAC rehabilitation for many patients with minimal mobility deficits. Although not all of the results were statistically significant, positive effects on hospital ratings show promise toward helping to improve the overall patient experience during admission, decreasing LOS, decreasing overall fall rate, and an associated decrease in GM patient PAC spending in those most likely to be affected by HAD related to immobility. These positive effects can potentially improve hospital profit margins through the Centers for Medicare & Medicaid Services' value-based purchasing reimbursement program.

P081. A Trust-Wide Breast Abscess Management and Referral Pathway

Introduction: NICE guidelines advise that patients presenting with breast abscesses are managed by ultrasound assessment followed by ultrasound guided-aspiration or incision and drainage. At Maidstone and Tunbridge Wells (MTW) NHS Trust, ultrasound for breast abscesses is only routinely performed by breast radiologists during one-stop breast clinics (OSBC). We sought to develop a referral pathway (RP) for patients who present to their GP or A&E to enable timely assessment and a standard operating procedure (SOP) for the emergency general surgical (GS) team.

South African General Surgeon Preparedness for Humanitarian Disasters.

Humanitarian medical organizations provide surgical care for a broad range of conditions including general surgical (GS), obstetric and gynecologic (OBGYN), orthopedic (ORTHO), and urologic (URO) conditions in unstable contexts. The most common humanitarian operation is cesarean section. The objective of this study was to identify the proportion of South African general surgeons who had operative experience and current competency in GS, OBGYN, ORTHO, and URO humanitarian operations in order to evaluate their potential for working in humanitarian disasters. This was a cross-sectional online survey of South African general surgeons administered from November 2017-July 2018. Rotations in OBGYN, ORTHO, and URO were quantified. Experience and competency in eighteen humanitarian operations were queried. There were 154 SA general surgeon participants. Prior to starting general surgery (GS) residency, 129 (83%) had OBGYN, 125 (81%) ORTHO, and 84 (54%) URO experience. Experience and competency in humanitarian procedures by specialty included: 96% experience and 95% competency for GS, 71% experience and 51% competency for OBGYN, 77% experience and 66% competency for ORTHO, and 86% experience and 81% competency for URO. 82% reported training, and 51% competency in cesarean section. SA general surgeons are potentially well suited for humanitarian surgery. This study has shown that most SA general surgeons received training in OBGYN, ORTHO, and URO prior to residency and many maintain competence in the corresponding humanitarian operations. Other low- to middle-income countries may also have broad-based surgery training, and the potential for their surgeons to offer humanitarian assistance should be further investigated.

Abstract: Comparative Evaluation of Smoking in Plastic versus General Surgical Postoperative Complications: A Propensity-Matched Analysis

INTRODUCTION: Smoking is an established modifiable risk factor for perioperative complications.1 This is especially relevant in elective plastic surgical (PS) than in urgent general surgical (GS) procedures. From 2005–2014, smoking rate among U.S. adults decreased from 20.9% to 16.8%. 2 This study compares smoking prevalence in patients undergoing plastic and general surgical procedures, and the postoperative complication profile when smoking is isolated as an independent risk factor. METHODS: We used the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine smoking and 30-day postoperative complications for plastic and general surgical procedures. Patients were propensity-score matched (PSM) for demographics and comorbidities to isolate smoking and minimize confounders. RESULTS: We examined 294,903 patients from 2005–2014. The smoking rates in GS cohort paralleled national trends (R=-0.85); smoking rates in PS patients were significantly lower for all years studied (p<0.01). After PSM, GS smokers continued to be more comorbid than respective nonsmokers, with greater incidences of diabetes, hypertension, dypsnea, and prior cardiac surgery (p<0.01); PS smokers were not significantly different than respective nonsmokers. Smokers had increased rates of superficial surgical site infections (SSI) (p<0.01), PE (p<0.01), and MI (p<0.02) for GS, but not for PS cohort. Both PS and GS smokers had increased dehiscence (p<0.01), deep SSI (PS: p=0.01, GS: p<0.01), and reoperation (p<0.01). Patients with ≥11 pack-years experienced significant increases in deep SSI (PS: p=0.02, GS: p=0.02) and reoperation (PS: p=0.05, GS: p<0.01). In GS smokers, ≥ 21 pack-years was associated with increased sepsis (p<0.01), MI (p=0.04) and organ/space SSI (p<0.01), and ≥ 31 pack-years was associated with increased dehiscence (p<0.01). PS cohorts had increased rates of wound complications for both smokers and non-smokers when compared to GS cohorts. CONCLUSION: This is the first propensity-matched, large-scale database analysis isolating smoking as a risk factor for postoperative complications in PS and GS procedures. The contrast in smoking rates between GS and PS patients highlights the differences in patient selection for urgent versus elective procedures. Our data indicates that smoking is an independent risk factor for PS and GS procedures. Smoking may also have different risk factor profiles for postoperative complications in PS versus GS patient populations emphasizing the need for caution when generalizing GS evidence for use in the PS population. Reference Citations: 1. Coon Devin, Tuffaha Sami, Christensen Joani, B. S. C. (2013). Plastic Surgery and Smoking. Plastic and Reconstructive Surgery, 132(4), 686e–687e. 2. Jamal, A., Homa, D. M., O’Connor, E., Babb, S. D., Caraballo, R. S., Singh, T., … King, B. A. (2015). Current Cigarette Smoking Among Adults - United States, 2005–2014. MMWR. Morbidity and Mortality Weekly Report, 64(44), 1233–40. http://doi.org/10.15585/mmwr.mm6444a2

Citation Characteristics of Basic Science Research Publications in General Surgical Journals 1, 2

Basic science research (BSR) publications in general surgical (GS) journals are an important "translational bridge" for practicing surgeons and surgical trainees. The purpose of this study is to characterize the BSR publications in GS journals and to analyze their citation frequencies. In 1996, all (224) BSR publications in the five highest rated U.S. GS journals (by impact factor) were reviewed, characterized, and their citation frequencies were compared to BSR publications in non-GS journals. On average, a BSR publication from these journals is cited 32 times (range 1-141, median 11). Half of the publications were cited more than 10 times in 6 years and 22% were cited twice, or more, within 1 year of publication. One in four publications were cited twice or more in journals with an impact factor greater than five. Citation frequencies of BSR publications in GS journals were related to the journal impact factor (P = 0.07), and to having a basic scientist (i.e., Ph.D.) as one of the authors (P < 0.01). Citation characteristics of BSR publications in GS journals were similar to those of BSR publications in non-GS journals with similar impact factors. We found that BSR publications in the U.S. GS journals studied had significant citation frequencies.

Predictors of postoperative outcome after general surgical procedures in patients with congenital heart disease

This study was undertaken to evaluate factors predictive of postoperative outcome after general surgical (GS) procedures in patients with congenital heart disease (CHD). All patients with a diagnosis of CHD who underwent a GS procedure under general anesthesia during a consecutive 10-year period were considered eligible for the study. The congenital heart defect was classified as either simple (ASD, VSD, PDA) or complex (endocardial cushion defects, transposition of the great vessels, tetralogy of Fallot), and the GS procedure as either major (intraperitoneal, intrathoracic, or vascular reconstructive) or minor (inguinal herniorrhaphy, vascular access). The overall mortality rate for the patient population was 12% (27 deaths among 226 procedures), minor procedures being associated with a 3% mortality rate (2 of 70 procedures), and major procedures with a 16% mortality rate (25 of 156 procedures). Incremental risk factors for mortality included a preoperative American Society of Anesthesiologists' (ASA) physical status class of IV or higher ( P = .0003), a preoperative in-hospital stay of 10 or more days ( P = .004), birth at a tertiary care center ( P = .04), and emergency operations ( P = .05). In the subgroup of patients less than 6 months old, weight of less than 2.4 kg at the time of surgery and a 1-minute Apgar score of less than 4 were additional independent risk factors ( P = .04 and .01, respectively). By logistic analysis, previous corrective cardiac procedures, whether complete or palliative, did not significantly alter the postoperative outcome. The authors conclude that physiologically well-compensated patients with CHD can undergo elective operations at a low operative risk; however, poorly compensated patients undergoing urgent or emergent operations are at high risk. Previous corrective cardiac procedures may improve the overall outcome if the physiological state of the patient could be improved.