COVID-19 Impact on Operative Management of Pediatric Neck Abscesses

Introduction  For multiple reasons, elective pediatric otolaryngology surgical procedures have declined during the COVID-19 pandemic. Objective  The purpose of the present study was to assess whether the prevalence of pediatric neck abscesses managed with operative drainage decreased compared with previous years. Methods  Medical records of all pediatric cases at a tertiary care children's hospital diagnosed with abscess of the neck and treated with incision and drainage were evaluated between the dates of April 1 and November 30 from 2015 to 2020. Outcomes were compared for each year from 2015 to 2019 to 2020, which included location, abscess size, duration of antibiotic treatment, microbiology, and the number of cases per year. Results  A total of 201 cases were included. The mean ± standard deviation (SD) presenting age in the 2015 to 2019 group was 5.05 ± 5.03 years old and 2.24 ± 1.91 years old in the 2020 group. The mean number of cases between 2015 and 2019 was 35.6 ± 4.2, whereas the number of cases in 2020 was 23 ( p  = 0.002). Of those patients who underwent IV antibiotic therapy prior to presentation ( n  = 43), the mean number of days before admission was 1.98 ± 2.95 ( n  = 40) from 2015 to 2019 and 12.00 ± 10.39 ( n  = 3) in 2020 ( p  = 0.008). The percent of cases with multiple strains cultured between 2015 and 2019 was 13.4% versus 18.2% in 2020 ( p  = 0.007). Conclusion  There was a decrease in the number of operative neck abscesses in 2020 compared with the mean number per year from 2015 to 2019. COVID-19 mitigation strategies leading to reduced transmission of other viral and bacterial illnesses and a tendency toward prolonged medical management to avoid surgery are two possible explanations.

Effect of the pandemic on surgical procedures in a tertiary care hospital: A retrospective review

Objectives

The aim of this study was to examine the impact of performing surgeries with necessary precautions and to evaluate demographic characteristics of operated patients during novel coronavirus-2019 (COVID-19) pandemic and the infection rates during hospitalization and within 14 days after surgery.

Material and Methods

Between March 15^th, 2020 and April 30^th, 2020, a total of 639 patients who had been operated on in our center were retrospectively analyzed. According to the triage system, the surgical procedures were classified as emergency, time-sensitive, and elective procedures. Data including age, sex, indication for surgery, the American Society of Anesthesiologists (ASA) class, pre- and postoperative symptoms, the presence and/ or absence of reverse transcriptase-polymerase chain reaction (RT-PCR) test result, type of surgery, surgical site, and documented COVID-19 infections during hospitalization and within 21 days after surgery were recorded.

Results

Of the patients, 60.4% were males and 39.6% were females with a mean age of 43.08 ± 22.68 years. Malignancy was the most common indication for surgery (35.5%), followed by trauma (29.1%). The abdominal area and head and neck region were the most frequent surgical sites in 27.4% and 24.9% of the patients, respectively. Of all surgical procedures, 54.9% were emergency and 43.9% were time-sensitive procedures. Of the patients, 84.2% were in ASA Class I-II while 15.8% patients were in ASA Class III, IV and V. General anesthesia was the most common anesthesia type in 83.9% of the patients. The overall rate of COVID-19 infection was 0.63% in the preoperative period. The rate of COVID-19 infection during and after surgery was 0.31%.

Conclusion

With similar infection rates to the general population, surgeries of all types can be performed safely taking preventive measures in the preand postoperative period. It would be wise to perform surgical treatment without delay in patients with an increased risk for mortality and morbidity in accordance with strict infection control principles.

Frozen section diagnosis of borderline ovarian tumors with suspicious features of invasive cancer is a devil's dilemma for the surgeon: A systematic review and meta-analysis

Introduction

Frozen section diagnoses of borderline ovarian tumors are not always straightforward and a borderline frozen section diagnosis with suspicious features of invasive carcinoma (reported as “at least borderline” or synonymous descriptions) presents us with the dilemma of whether or not to perform a full surgical staging procedure. By performing a systematic review and meta‐analysis, the prevalence of straightforward borderline and “at least borderline” frozen section diagnoses, as well as proportion of patients with a final diagnosis of invasive carcinoma in these cases, were assessed and compared, as quantification of this dilemma may help us with the issue of this clinical decision.

Material and methods

PubMed, EMBASE and Cochrane library databases were searched and studies discussing “at least borderline” frozen section diagnoses were included in the review. Numbers of specific frozen section diagnoses and subsequent final histological diagnoses were extracted and pooled analysis was performed to compare the proportion of patients diagnosed with invasive carcinoma following borderline and “at least borderline” frozen section diagnoses, presented as risk ratio and risk difference with 95% confidence intervals (95% CI).

Results

Of 4940 screened records, eight studies were considered eligible for quantitative analysis. A total of 921 women was identified and 230 (25.0%) of these women were diagnosed with “at least borderline” ovarian tumor at the time of frozen section. Final histological diagnoses were reported in five studies, including 61 women with an “at least borderline” diagnosis and 290 women with a straightforward borderline frozen section diagnosis. Twenty‐five of 61 women (41.0%) of the “at least borderline” group had invasive cancer at final diagnosis, compared with 28 of 290 women (9.7%) of the straightforward borderline frozen section group (risk difference −0.34, 95% CI −0.53 to −0.15; relative risk 0.25, 95% CI 0.13–0.50).

Conclusions

Women diagnosed with “at least borderline” frozen section diagnoses were found to have a higher chance of carcinoma upon final diagnosis when compared with women with a straightforward borderline frozen section diagnosis (41.0% vs 9.7%). Especially in the serous subtype, and after preoperative consent, full staging during initial surgery might be considered in these cases to prevent a second surgical procedure.

Extracorporeal life support to ventricular assist device: potential benefits of sternal-sparing approach

Background

Advancements in left ventricular assist device (LVAD) technology have improved long-term survival for properly selected patients with advanced heart failure. However, the subset of patients in critical cardiogenic shock remain difficult to treat with persistently high patient morbidity and mortality. The goal of this study is to describe our institutional experience utilizing extracorporeal membrane oxygenation (ECMO) as a bridge to LVAD for patients in cardiogenic shock comparing the less invasive complete sternal-sparing (CSS) surgical technique to median sternotomy.

Methods

Data was collected as a single center retrospective review of patients implanted with a continuous-flow LVAD directly off ECMO from 2012 to 2018. Patients were stratified by LVAD surgical technique. The primary outcome was survival to discharge. Secondary outcomes included postoperative complications, resource utilization and survival at 6-months.

Results

Of the 37 patients implanted directly off ECMO, 26 (70%) patients were implanted via median sternotomy and 11 (30%) patients by the CSS approach. Median time on ECMO support was 8 days (range, 2-29 days). Preoperative characteristics were similar between groups. Survival to discharge was 78% overall (73% vs. 91% CSS, P=0.391). The CSS cohort had fewer postoperative complications, including fewer transfusions (P=0.044) and trend towards less right ventricular (RV) failure (62% vs. 27% CSS, P=0.079). Both cohorts required similar median length of stay (LOS) in the intensive care unit (ICU) (11 vs. 12 days, P=0.695) and similar overall hospital LOS (34 vs. 22 days, P=0.242). Overall survival was 74% at six months (68% vs. 89% CSS, P=0.386).

Conclusions

VA ECMO can be used effectively as a bridge-to-LVAD for patients in cardiogenic shock. The less invasive CSS approach demonstrates potential advantages to median sternotomy. Further study is needed to better understand the benefits of less invasive surgical techniques.

[Complex supportive care of patients with breast cancer. The preliminary results of a psychological intervention study]

Introduction: Interdisciplinary studies confirm that the traumatic nature of cancer diagnosis and the long course of treatment may often lead to a series of emotional problems among cancer patients, this way precluding physical and psychological recovery. Aim: The aim of the study was to create a complex psychosocial intervention program for breast cancer patients and to present our preliminary results. Method: In our 6 week long study, 50 breast cancer patients were assessed. The intervention group comprised of 20 patients, the control group comprised of 30 patients. Measurements included the Beck Depression Inventory (BDI), the Spielberger State and Trait Anxiety Inventory (STAI), the Surgical Fear Questionnaire (SFQ), the Visual Analogue Scale (VAS), the Functional Assessment of Cancer Therapy - Breast (FACT-B) and the Breast-Impact of Treatment Scale (BITS). Therapeutic tools used were the PRISM-D and the Body-Sculpture Test. Results: Our results indicate that the psychological interventions may have an instant stress-relieving and calming effect on our patients, this way providing social support. The type of surgery significantly influenced the levels of body change stress. Conclusion: Our results highlight the importance of early psychological screening among breast cancer patients before and after surgery as well. Orv Hetil. 2019; 160(18): 700-709.

[The reliability and validity of the Hungarian version of the Surgical Fear Questionnaire]

INTRODUCTION

Interdisciplinary studies confirm that surgical fear experienced by patients can have a substantial effect on the outcome of the surgery and the healing process after surgery.

AIM

The aim of this study was to assess the reliability and validity of the Hungarian version of the Surgical Fear Questionnaire in cancer patients.

METHOD

149 patients were assessed using the Spielberger Anxiety Inventory, the Beck Depression Inventory, the Visual Analogue Scale and the Surgical Fear Questionnaire.

RESULTS

The scale showed excellent internal consistency (Cronbach-alfa = 0.878; 0.885). The Surgical Fear Questionnaire scores moderately correlated with anxiety, depression and anticipated pain after surgery.

CONCLUSION

The reliability and validity of the Hungarian version of the Surgical Fear Questionnaire in the sample were excellent. The questionnaire turned out to be a useful psychometric tool in the measurement of surgical fear. Orv Hetil. 2018; 159(47): 1988-1993.

The role of subgaleal suction drain placement in chronic subdural hematoma evacuation

Introduction:

There is lack of uniformity about the preferred surgical treatment, role of drain, and type of drain among various surgeons in chronic subdural hematoma (CSDH). The present study is aimed to evaluate role of subgaleal drain.

Materials and Methods:

This was a prospective study of 260 patients of CSDH treated surgically. Burr-hole irrigation with and without suction drain was done in 140 and 120 patients, respectively. Out of 120 patients without suction drain 60 each were managed by single and two burr holes. Pre- and postoperative GCS was recorded. Recurrent hematomas, CSDH secondary to tumor, due to intracranial hypotension, coagulopathy, children below 18 years, and patients treated by twist drill craniostomy or craniotomy were excluded. Subgaleal closed-system drainage with low negative pressure was used.

Results:

Age of the patients ranged from 18 to 75 years with mean age of 57 years. There were 9, 47, 204 patients in GCS of 3-8, 9-12, and 13-15, respectively. Both the groups were comparable in terms of age, etiology, gender, and neurological status. There was no difference in the mortality in both the group. The recurrence and postoperative pneumocephalus was significantly less in suction drain group as compared to without drain group. There was no infection or any other complication related to suction drainage.

Conclusion:

Subgaleal closed suction drainage was safe, simple, and effective in the management of CSDH. Recurrence rate was low in the suction drain group.

Chronic subdural hematoma

Chronic subdural hematoma (CSDH) is one of the most common neurosurgical conditions. There is lack of uniformity in the treatment of CSDH amongst surgeons in terms of various treatment strategies. Clinical presentation may vary from no symptoms to unconsciousness. CSDH is usually diagnosed by contrast-enhanced computed tomography scan. Magnetic resonance imaging (MRI) scan is more sensitive in the diagnosis of bilateral isodense CSDH, multiple loculations, intrahematoma membranes, fresh bleeding, hemolysis, and the size of capsule. Contrast-enhanced CT or MRI could detect associated primary or metastatic dural diseases. Although definite history of trauma could be obtained in a majority of cases, some cases may be secondary to coagulation defect, intracranial hypotension, use of anticoagulants and antiplatelet drugs, etc., Recurrent bleeding, increased exudates from outer membrane, and cerebrospinal fluid entrapment have been implicated in the enlargement of CSDH. Burr-hole evacuation is the treatment of choice for an uncomplicated CSDH. Most of the recent trials favor the use of drain to reduce recurrence rate. Craniotomy and twist drill craniostomy also play a role in the management. Dural biopsy should be taken, especially in recurrence and thick outer membrane. Nonsurgical management is reserved for asymptomatic or high operative risk patients. The steroids and angiotensin converting enzyme inhibitors may also play a role in the management. Single management strategy is not appropriate for all the cases of CSDH. Better understanding of the nature of the pathology, rational selection of an ideal treatment strategy for an individual patient, and identification of the merits and limitations of different surgical techniques could help in improving the prognosis.

Robotic surgery for benign duodenal tumors

INTRODUCTION

Benign duodenal and periampullary tumors are uncommon lesions requiring careful attention to their complex anatomic relationships with the major and minor papillae as well as the gastric outlet during surgical intervention. While endoscopy is less morbid than open resection, many lesions are not amenable to endoscopic removal. Robotic surgery offers technical advantages above traditional laparoscopy, and we demonstrate the safety and feasibility of this approach for a variety of duodenal lesions.

METHODS

We performed a retrospective review of all robotic duodenal resections between April 2010 and December 2013 from two institutions. Demographic, clinicopathologic, and operative details were recorded with special attention to the post-operative course.

RESULTS

Twenty-six patients underwent robotic duodenal resection for a variety of diagnoses. The majority (88 %) were symptomatic at presentation. Nine patients underwent transduodenal ampullectomy, seven patients underwent duodenal resection, six patients underwent transduodenal resection of a mass, and four patients underwent segmental duodenal resection. Median operative time was 4 h with a median estimated blood loss of 50 cm(3) and no conversions to an open operation. The rate of major Clavien-Dindo grades 3-4 complications was 15 % at post-operative days 30 and 90 without mortality. Final pathology demonstrated a median tumor size of 2.9 cm with a final histologic diagnoses of adenoma (n = 13), neuroendocrine tumor (n = 6), gastrointestinal stromal tumor (GIST) (n = 2), lipoma (n = 2), Brunner's gland hamartoma (n = 1), leiomyoma (n = 1), and gangliocytic paraganglioma (n = 1).

CONCLUSION

Robotic duodenal resection is safe and feasible for benign and premalignant duodenal tumors not amenable to endoscopic resection.

Learning curve for breast mass excision using a vacuum-assisted biopsy system

BACKGROUND

Vacuum-assisted breast biopsy system (VAB) is an alternative modality to core needle biopsy for the diagnosis of breast lesions.

MATERIAL AND METHODS

Fifty-four patients who underwent ultrasound-guided VAB procedures were analyzed. Patients were categorized into two groups: The first 20 consecutive patients as group A and the next 34 consecutive patients as group B.

RESULTS

Fifty-two patients underwent excision, and two underwent biopsy only. Moving average curves showed a plateau phase for performing VAB procedures after the 20(th) patient. Total operation times of group B were significantly shorter than those of group A (p < 0.001). Complication rates in group B tended to be lower, and VAB probe position of group B tended to be better than that of group A, but these differences were not statistically significant.

CONCLUSION

Our data suggest the existence of a learning curve for ultrasound-guided VAB procedures. VAB procedures can be performed safely, even during the early learning period.

Evaluating the value and impact of the Victorian Audit of Surgical Mortality

INTRODUCTION

Since the Victorian Audit of Surgical Mortality (VASM) commenced in 2007, 95% of Victorian Fellows have agreed to participate and have provided data on the deaths of patients receiving surgical care. All public, and the majority of private, hospitals involved in the delivery of surgical services in Victoria have been submitting data on deaths associated with surgery. De-identified reports on this data are distributed in regular annual reports and case note review booklets. Although informal feedback on the perceived value of the audit was encouraging, a formal review of all aspects of the audit was felt necessary.

METHODS

An independent formal review of VASM governance, documentation, datasets and data analysis was performed, in addition to a survey of 257 individuals (surgeons and other stakeholders) on the perceived impact of VASM.

RESULTS

The review confirmed increasing participation and acceptance by surgeons since the inception of the project. Governance mechanisms were found to be effective and acknowledged by stakeholders and collaborators. Robust participation rates have been achieved, and stakeholders were generally satisfied with the quality of feedback. Suggestions for improvement were provided by some surgeons and hospitals.

CONCLUSION

External review of VASM processes and procedures confirmed that the audit was operating effectively, with robust quality control and achieving the trust of stakeholders. The educational value of the audit to the surgical community was acknowledged and areas for future improvement have been identified.