RSS 1.0General Surgery
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Low vs. conventional intra-abdominal pressure in laparoscopic colorectal surgery : a prospective cohort studyA total of 120 patients were included of which 69 (57.5%) were male. Median age and BMI of the cohort was 67 years (51-75 years) and 27 kg/m2 (24-32 kg/m2), respectively. 61 (50.8%) patients were categorised as an ASA grade 3. Two (1.7%) patients had diverticular disease; 31 (25.9%) had IBD, and 87 (72.4%) were operated on for colonic malignancy. Low IAP (8mmHg) was used in 53 (44.2%) cases, whilst the remainder (55.8%) had IAP set at 15mmHg (conventional). Low-pressure surgery was associated with improved intraoperative lung compliance (p < 0.001) and peak inspiratory pressures up to 6 h (p < 0.001); reduced analgesic requirement (p ≤ 0.028), and decreased postoperative pain both at rest (p = 0.001) and on exertion (p < 0.001). Moreover, low IAP was associated with an earlier time to pass flatus postoperatively (p = 0.047) with no significant difference in length of hospital stay (p = 0.574). Additionally, no significant difference was observed between the groups for outcomes including median operating time (p = 0.089), conversion to open surgery (p = 0.056), overall complication rate (p = 0.102), and 90-day mortality (p = 0.381).
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Appropriateness of small molecule agents for patients with IBD of childbearing age - a RAND/UCLA appropriateness panelSelinger C, Laube R, Limdi JK, Headley K, Kent A, Kok K, Fraser A, Newman V, Ludlow H, Rees F, Sagar N, Walker E. Appropriateness of small molecule agents for patients with IBD of childbearing age - a RAND/UCLA appropriateness panel. Therap Adv Gastroenterol. 2024 Nov 13;17:17562848241299737. doi: 10.1177/17562848241299737. PMID: 39539488; PMCID: PMC11558739.
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De Garengeot Hernia : a case report of an incidental findingDe Garengeot hernia is a rare occurrence characterised by the presence of the appendix within a femoral hernia. This type of hernia is notable for its rare anatomical presentation. In rare instances, the appendix can present as inflamed or necrotic in which case it may present as an emergency. In many instances, De Garengeot hernia is discovered incidentally during surgical repair of a hernia. This incidental finding raises an important consideration for surgeons. This study reports a case of De Garengeot hernia identified as an incidental intraoperative finding. It aims to enhance awareness of the condition, ultimately improving patient outcomes and management.
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Comparison of one-year outcomes in sleeve gastrectomy vs. one anastomosis gastric bypass in a single bariatric unitIntroduction Sleeve gastrectomy (SG) is the most popular bariatric procedure worldwide in terms of numbers performed. However, there has been a rise in the popularity of the one anastomosis (mini) gastric bypass (OAGB). There have been various studies comparing the outcomes of SG vs OAGB and this study aims to add our experience and compare one-year outcome data between SG and OAGB in a single UK bariatric centre. Methods A retrospective search of our database between June 2021 and August 2023 was performed to identify those patients undergoing either laparoscopic SG or OAGB. Initial and one-year follow-up data was collected including percentage total weight loss (%TWL), percentage excess body weight loss (%EBWL), incidence of post-operative reflux, remission of co-morbidities (diabetes), glycated haemoglobin (HbA1c) changes, operating time and post-operative complications. Results A total of 64 OAGB and 53 SG patients were identified in this time frame. Nineteen OAGB and 26 SG patients had one-year outcome data available and so were included in the final analysis. Pre-op BMI was significantly lower in the OAGB group (OAGB = 47.1, SG = 52.7, p<0.05). Initial age, rates of pre-operative gastro-oesophageal reflux symptoms and pre-operative diabetes were comparable. Regarding one-year outcomes, %EBWL was comparable, as was the length of stay, reduction in HbA1c and resolution of diabetes. Operating time was significantly shorter in the SG group (OAGB = 140 mins, SG = 111 mins, p<0.05). While the number of patients with post-operative complications was the same in both groups, two patients in the OAGB group suffered from ulcer disease with one requiring a return to theatre for this. No patients in the SG group suffered from ulcer disease. One OAGB patient required conversion to Roux-en-Y gastric bypass (RYGB) for reflux, while three SG patients required conversion to RYGB for resistant reflux. Conclusion Both OAGB and SG patients in our centre have comparable outcomes with regard to excess body weight loss and resolution of diabetes. SG was quicker to perform. OAGB may be associated with higher rates of ulceration while SG may be associated with higher rates of treatment-resistant reflux requiring conversion surgery. The literature has revealed greater weight loss and increased rates of diabetes resolution with OAGB. This along with our findings will be considered when counselling our patients on the bariatric procedures available to them.
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Retrospective analysis of specimen quality in temporal artery biopsies for giant cell arteritis and disease association in North Midlands, EnglandBackground Temporal artery biopsy (TAB) is the recommended index diagnostic method for giant cell arteritis (GCA). Per the British Society for Rheumatology (BSR) guidelines, we assessed our procedural performance. Additionally, we evaluated the occurrence of GCA diagnosis in immunosuppressed patients and other comorbidities. Methods Following the audit registration, a retrospective analysis of prospectively collected data was conducted from 2017 to 2022 at a large university hospital in North Midlands, England. Data on demographics and comorbidities were gathered. The study's primary outcome was adherence to BSR guidelines and our service provisions. Secondary outcomes included examining the relationship between biopsy-confirmed GCA and other comorbidities. Statistical analysis was carried out using SPSS version 29 (IBM Corporation, Armonk, New York, United States of America). Two-sample t-test and Chi-square/Fisher exact test were used for continuous and categorical variables, respectively. Holm-Bonferroni method was incorporated to adjust for multiple comparisons. Results A total of 156 patients who underwent temporal artery biopsy (TAB) were included in the study, with a male-to-female ratio of 0.44:1. The median age was 73. Among the patients, 19% were smokers. The procedures were performed by either a vascular surgeon (119, 76%) or by an ophthalmologist (37, 24%). Two-thirds of the patients underwent TAB within seven days of referral. In 73, 47% of cases, the post-fixation biopsy sample size exceeded 10 mm. Positive biopsy results were found in 45 patients (29%). GCA was confirmed in 39% of patients with polymyalgia rheumatica (PMR), 24% with diabetics, 20% with hypothyroidism, 29% with hypertension, 32% with hyperlipidaemia, and 26% with other inflammatory diseases. However, the p-value was below the statistically significant threshold. The biopsy outcome was also not dependent on the speciality, time from referral to biopsy, nor on the length of the post-fixation specimen. Conclusions Temporal artery biopsy remains a valuable and crucial diagnostic tool in challenging equivocal cases of giant cell arteritis (GCA), although it is limited by its sensitivity, but there is also room for improvement. There is still uncertainty regarding the relationship between biopsy positivity, post-fixation sample size, and the interval between referral and procedure. Additionally, the speciality of the clinician performing the biopsy does not appear to significantly influence the likelihood of a positive result. We still do not fully understand why this is, but the association of the GCA with other comorbidities was unpredictably insignificant.
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Polyurethane versus calcium alginate dressings for split-thickness skin graft donor site : a systematic review and meta-analysisHerein, we compare the outcomes of polyurethane and calcium alginate dressings for split-thickness skin graft (STSG) donor sites. A systematic review and meta-analysis were conducted with a search of electronic databases to identify all randomised controlled trials (RCTs) and observational studies comparing the outcomes of polyurethane dressing versus calcium alginate for STSG donor sites. Primary outcomes were pain intensity, convenience for staff and patients, and adverse effects (namely, excessive exudate, infection rate, and hematoma). Secondary outcome measures included the assessment of healing, dressing changes, cosmetic appearance, and cost. Fixed and random-effect models were used for the analysis. Four RCTs enrolling 127 subjects were identified. There was no significant difference between polyurethane and calcium alginate in terms of pain intensity on Day 1 (mean difference (MD) 0.13, P = 0.80) and Day 5 (MD = 0.20, P = 0.38), as well as the ease of application (odds ratio (OR) = 3.08, P = 0.47). However, there was a statistically significant improvement in patient comfort, favouring the polyurethane group (OR = 44.11, P < 0.00001). In addition, no statistically significant differences were noted in terms of adverse effects between the two dressings. In terms of cost, the calcium gluconate dressing had an overall higher cost compared to polyurethane. Polyurethane is a more favourable dressing compared to calcium alginate for STSG donor sites in terms of patient comfort, healing, and cosmetic outcomes. However, comparable results were noted in terms of pain intensity, ease of application, and adverse effects profile. Cost-effectiveness analysis studies are required to justify its routine use.
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The role of Neutrophil-Lymphocyte-Ratio (NLR) and Platelet-Lymphocyte-Ratio (PLR) as a biomarker for distinguishing between complicated and uncomplicated appendicitisIntroduction Acute appendicitis (AA) is one of the most common acute general surgical presentations affecting 7% of the population at some point in their lifetime. The ability to assess the risk of complicated appendicitis (CA) from uncomplicated appendicitis (UA) in acute appendicitis (AA) could reduce the associated morbidity and mortality. The value of platelet lymphocyte ratio (PLR) as an inflammatory marker increases when its fluctuations are interpreted along with other complementary hematologic indices, such as neutrophil-to-lymphocyte ratio (NLR), which provides additional information about the disease activity. Hence, we postulated that NLR and/or PLR could serve as a potential surrogate marker in assessing the severity of AA. Aim This study aims to investigate the use of PLR and/or NLR as a surrogate biomarker in differentiating uncomplicated from complicated appendicitis. Material and methods This retrospective study was conducted at Russells Hall Hospital from January 1, 2017, to December 31, 2020. Data of all patients over age 16 years that had histologically confirmed appendicitis were retrieved. NLR and PLR were calculated from the admission hemogram, and the ratios were compared between uncomplicated (UA) or complicated appendicitis (CA). Cut-off values were calculated using the summarized ROC curve; in addition, the sensitivity and specificity with 95% confidence intervals were determined using SPSS 25.0 (IBM Corp., Armonk, NY). Results A total of 799 patients were analyzed, of which 469 (58.7%) were female. The median age was 31.2 years. The difference between NLR and PLR within the two appendicitis groups was significant (P=0.05; Kruskal-Wallis). Cohen's kappa (degree of inter-rater agreement) between NLR and PLR showed a moderate agreement of 0.589 (P<0.001). We equally demonstrated an exponential relationship between PLR and NLR (R2 =0.510, P<0.05). For UA, the area under the curve (AUC) and the cut-off for NLR and PLR were 0.715, 4.75 with a confidence interval (CI) of 0.678-0.653 and 0.632, 155 with a CI of 0.591-0.672, respectively. For CA, using NLR and PLR, the AUC and cut-off were 0.727, 6.96 with a CI of 0.687-0.768 and 0.653, 180.5 with a CI of 0.602-0.703, respectively; all were significant with a P of <0.001. Conclusion NLR and PLR are a reliable, less cumbersome surrogate biomarker for assessing the severity of acute appendicitis.
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Radiofrequency as a method of localizing impalpable breast lesionsBackground: The incidence of early stage breast cancer has risen as a result of increased detection of non-palpable tumors through the implementation of screening programs and greater public awareness. Performing breast-conserving surgery can be challenging due to the need for accurate localization of non-palpable breast lesions, particularly given the logistical difficulties associated with wire localization. After implementing a new technique for localizing non-palpable breast lesions (LOCalizerTM Radiofrequency identification TAG-Hologic®), a radiofrequency identification tag localization device manufactured by Hologic, Inc. in Marlborough, MA, was launched in 2017, our objective was to investigate its impact on surgical outcomes, whether there was an increase in re-excision rates for positive margins and whether the attainment of clear margins was dependent on the exact positioning of the RFID device. Method: A single-center single-arm interventional study, data were gathered both in a forward-looking manner for 1 year (prospectively) and by looking back at past records for 1 year (retrospectively) for a total period of two years. Individuals who were diagnosed with non-palpable breast lesions, as confirmed by histological analysis, or invasive breast cancer and who were scheduled to undergo breast-conserving surgery were eligible for inclusion in the study. The RFID (Radiofrequency Identification) method was used to localize the lesions prior to surgery. Either with a mammogram or ultrasound scan position of the Tag was recorded, including the distance of the lesion from the center of the lesion and the lesion depth from the skin in millimeters. The rate of re-excision was documented and examined in relation to the parameters mentioned above. Results: Two hundred and twenty RFID Tags were inserted in two hundred and seventeen (three patient had bilateral tags insertion), patients aged between 30 and 85 had a localizer Tag inserted between Oct 2020 and Oct 2022. Three patients had non-palpable breast lesions in both breasts. Fourteen were inserted under stereotactic guidance and two hundred and six under ultrasound guidance. Ten patients subsequently had wire insertion also due to Tag position. Of 210 procedures, RFIF Tags within the lesion was seen in hundred and sixty patients (76.19 %). An additional 50 procedures were performed using the RFID Tag system, which were not directly related to the lesion but were deemed appropriate to proceed with. Out of a total of 220 procedures, positive margins were observed in 38 cases (17.27 %). Among these cases, eleven (28.94 %) involved the use of the RFID Tag system, not within the lesion but adjacent to it (within 15 mm surrounding the lesion). Conclusion: RFID is a good alternative to wire localization of non-palpable breast lesions. Re-excision rates are higher in patients with Tag outside the lesion compared to those with Tag within the lesion.
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Revision/conversion surgeries after one anastomosis gastric bypass - an experts' modified Delphi consensusPurpose: There is a lack of evidence for treatment of some conditions including complication management, suboptimal initial weight loss, recurrent weight gain, or worsening of a significant obesity complication after one anastomosis gastric bypass (OAGB). This study was designed to respond to the existing lack of agreement and to provide a valuable resource for clinicians by employing an expert-modified Delphi consensus method. Methods: Forty-eight recognized bariatric surgeons from 28 countries participated in the modified Delphi consensus to vote on 64 statements in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was regarded to indicate a consensus. Results: A consensus was achieved for 46 statements. For recurrent weight gain or worsening of a significant obesity complication after OAGB, more than 85% of experts reached a consensus that elongation of the biliopancreatic limb (BPL) is an acceptable option and the total bowel length measurement is mandatory during BPL elongation to preserve at least 300-400 cm of common channel limb length to avoid nutritional deficiencies. Also, more than 85% of experts reached a consensus on conversion to Roux-en-Y gastric bypass (RYGB) with or without pouch downsizing as an acceptable option for the treatment of persistent bile reflux after OAGB and recommend detecting and repairing any size of hiatal hernia during conversion to RYGB. Conclusion: While the experts reached a consensus on several aspects regarding revision/conversion surgeries after OAGB, there are still lingering areas of disagreement. This highlights the importance of conducting further studies in the future to address these unresolved issues.
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The impact of obesity on reflux recurrence following Laparoscopic anti-reflux surgery : an evidence-based systematic review and meta-analysisGastroesophageal reflux disease (GERD) is frequently seen in the Western population. Laparoscopic anti-reflux surgery (LARS) is effective in managing this condition. Obesity is strongly associated with GERD, and with the rising rate of obesity, there is, therefore, a concurrently increasing frequency of LARS performed. We aim to review the outcomes of LARS in patients with obesity, including the recurrence of GERD symptoms and peri-operative complications. A systematic review and meta-analysis were performed for articles from June 1992 to June 2022. The literature was reviewed for outcomes of LARS in patients with obesity (BMI≥30). Eligibility criteria included specific BMI, study design, type of surgery, and outcomes. The recurrence of symptoms and peri-operative complications were assessed. Thirty-one studies were thoroughly reviewed. Nine studies (five retrospective and four prospective) were selected for meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow, which included 1,499 patients with obesity and 5,521 without. Laparoscopic Nissen fundoplication was the most common procedure performed. The recurrence of symptoms was significantly lower in patients without obesity (p=0.0001). There was no statistically significant difference between patients with and without obesity in peri-operative complications, re-intervention, and early return to theatres. A higher recurrence rate of GERD symptoms post-LARS was reported in patients with obesity. Further research is required to decrease such risks and propose different methods, such as weight loss prior to surgery or Roux-en-Y (R&Y) gastric bypass. Risks and benefits should be considered by clinicians prior to offering LARS to patients with obesity.
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Laparoscopic cholecystectomy performed by a surgical care practitioner : a review of outcomesIntroduction: Surgical care practitioners (SCPs) are non-medical workers involved in various aspects of the management of surgical patients. The role includes assisting and performing surgical procedures. More than 60,000 laparoscopic cholecystectomies (LC) are performed annually in the UK. With ever-increasing pressure on waiting lists, it is important to look at fully utilising the skills of our entire workforce. We report what we believe is the first published series of LC performed by an SCP. Methods: A retrospective review of a prospectively collected database was performed. The primary outcome was any complication requiring intervention. Secondary outcomes were minor complications, operative time, length of stay, conversion and readmission. Results: In total, 170 patients were operated on. Indications were biliary colic in 127 (74.7%), cholecystitis in 30 (17.6%) and pancreatitis in 13 (7.6%). Mean operating time was 65min (range 35-152min). Fifty-three operations were assisted by a consultant, 110 by a specialist or associate specialist grade (SAS) doctor and 7 by a core trainee (CT2). Some 139 (81.7%) patients were discharged on the day of surgery and 24 (14.1%) stayed one night in hospital. There were no major complications. Five patients required readmission, three with pain and two with port site infections. There were no conversions or transfusions required. Conclusions: There is a paucity of published data on surgical outcomes of procedures performed by SCPs. With a structured, supervised approach, SCPs could be trained to take on more complex procedures and further strengthen the surgical workforce. This study demonstrates that elective LC can be safely performed by an appropriately trained and supervised SCP. Keywords: Cholecystectomy, laparoscopic; Clinical nurse specialist; Development, staff; Nurse practitioner.
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Current recommendations for procedure selection in class I and II obesity developed by an expert modified Delphi consensusMetabolic and bariatric surgery (MBS) is widely considered the most effective option for treating obesity, a chronic, relapsing, and progressive disease. Recently, the American Society of Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) issued new guidelines on the indications for MBS, which have superseded the previous 1991 National Institutes of Health guidelines. The aim of this study is to establish the first set of consensus guidelines for selecting procedures in Class I and II obesity, using an Expert Modified Delphi Method. In this study, 78 experienced bariatric surgeons from 32 countries participated in a two-round Modified Delphi consensus voting process. The threshold for consensus was set at an agreement or disagreement of ≥ 70.0% among the experts. The experts reached a consensus on 54 statements. The committee of experts reached a consensus that MBS is a cost-effective treatment option for Class II obesity and for patients with Class I obesity who have not achieved significant weight loss through non-surgical methods. MBS was also considered suitable for patients with Type 2 diabetes mellitus (T2DM) and a body mass index (BMI) of 30 kg/m2 or higher. The committee identified intra-gastric balloon (IGB) as a treatment option for patients with class I obesity and endoscopic sleeve gastroplasty (ESG) as an option for patients with class I and II obesity, as well as for patients with T2DM and a BMI of ≥ 30 kg/m2. Sleeve gastrectomy (1) and Roux-en-Y gastric bypass (RYGB) were also recognized as viable treatment options for these patient groups. The committee also agreed that one anastomosis gastric bypass (OAGB) is a suitable option for patients with Class II obesity and T2DM, regardless of the presence or severity of obesity-related medical problems. The recommendations for selecting procedures in Class I and II obesity, developed through an Expert Modified Delphi Consensus, suggest that the use of standard primary bariatric endoscopic (IGB, ESG) and surgical procedures (SG, RYGB, OAGB) are acceptable in these patient groups, as consensus was reached regarding these procedures. However, randomized controlled trials are still needed in Class I and II Obesity to identify the best treatment approach for these patients in the future.
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Exploring the mechanisms behind autologous lipotransfer for radiation-induced fibrosis : a systematic reviewAim: Radiation-induced fibrosis is a recognised consequence of radiotherapy, especially after multiple and prolonged dosing regimens. There is no definitive treatment for late-stage radiation-induced fibrosis, although the use of autologous fat transfer has shown promise. However, the exact mechanisms by which this improves radiation-induced fibrosis remain poorly understood. We aim to explore existing literature on the effects of autologous fat transfer on both in-vitro and in-vivo radiation-induced fibrosis models, and to collate potential mechanisms of action. Method: PubMed, Cochrane reviews and Scopus electronic databases from inception to May 2023 were searched. Our search strategy combined both free-text terms with Boolean operators, derived from synonyms of adipose tissue and radiation-induced fibrosis. Results: The search strategy produced 2909 articles. Of these, 90 underwent full-text review for eligibility, yielding 31 for final analysis. Nine conducted in-vitro experiments utilising a co-culture model, whilst 25 conducted in-vivo experiments. Interventions under autologous fat transfer included adipose-derived stem cells, stromal vascular function, whole fat and microfat. Notable findings include downregulation of fibroblast proliferation, collagen deposition, epithelial cell apoptosis, and proinflammatory processes. Autologous fat transfer suppressed hypoxia and pro-inflammatory interferon-γ signalling pathways, and tissue treated with adipose-derived stem cells stained strongly for anti-inflammatory M2 macrophages. Although largely proangiogenic initially, studies show varying effects on vascularisation. There is early evidence that adipose-derived stem cell subgroups may have different functional properties. Conclusion: Autologous fat transfer functions through pro-angiogenic, anti-fibrotic, immunomodulatory, and extracellular matrix remodelling properties. By characterising these mechanisms, relevant drug targets can be identified and used to further improve clinical outcomes in radiation-induced fibrosis. Further research should focus on adipose-derived stem cell sub-populations and augmentation techniques such as cell-assisted lipotransfer.
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Component separation repair of incisional hernia : evolution of practice and review of long-term outcomes in a single centerPurpose: To review the long-term outcomes of complex abdominal wall reconstruction using anterior and posterior component separation (CS) techniques in our center. Methods: This was a descriptive analytical study. Analysis of data from a prospectively collected database of patients who had undergone Component Separation (CS) repair of incisional hernias was performed. Two techniques were used. Anterior component separation (ACS) and posterior component separation with transversus abdominis release (PCS/TAR). Follow-up was clinical review at 6 weeks, 6 months, and 12 months with direct access telephone review thereafter. Long-term outcome data was obtained from electronic records and based on either clinical or CT assessment. Minimum physical follow-up was 6 months for all patients. Results: 89 patients with large incisional hernias underwent CS repair. 29 patients had ACS while 60 underwent PCS/TAR. Mean follow-up was 60 months (range 6-140 months) in the ACS group and 20 months (range 6-72 months) in the PCS group. Twenty-five patients (28%) had simultaneous major procedures including 21 intestinal anastomoses. Twenty-six (29%) of patients had associated stomas. Twenty-seven (30.3%) of the patients had undergone previous hernia repairs. Seromas occurred in 24 (26.97%) patients. Wound infections were more common after ACS. There have been 10 (11.2%) recurrences to date. Conclusion: Component separation repair techniques result in good long-term outcomes with acceptable complication rates. They can be performed simultaneously with gastrointestinal procedures with low morbidity. Appropriate patient selection and use of appropriate mesh are important.
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Does omentopexy make a difference in laparoscopic sleeve gastrectomy for obesity treatment? A systematic review and meta-analysisThis systematic review and meta-analysis aimed to evaluate the comparative outcomes of laparoscopic sleeve gastrectomy with omentopexy (LSGO) versus conventional laparoscopic sleeve gastrectomy (LSG) for obesity treatment. A systematic online search was conducted using the available online databases, and Revman software was used for data analysis. Twenty-two eligible comparative studies were included (n = 9,321). LSGO showed a significantly lower rate of gastric leak (P = 0.0001), staple line bleeding (P = 0.00001), and gastric torsion (P = 0.002) in comparison to the LSG group. Operative time was significantly shorter in the LSG group (P = 0.00001); however, the length of hospital stay was in favour of the LSGO (P = 0.00001). Compared to LSG without omentopexy, LSG with omentopexy provides a significantly lower rate of postoperative complications and shorter LOS at the expense of operative time.
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Tracheostomy obstruction refractory to conventional management strategiesNo abstract available.
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The perceived global impact of the COVID-19 pandemic on doctors' medical and surgical training : an international surveyIntroduction: The COVID-19 pandemic has resulted in a significant burden on healthcare systems causing disruption to the medical and surgical training of doctors globally. Aims and objectives: This is the first international survey assessing the perceived impact of the COVID-19 pandemic on the training of doctors of all grades and specialties. Methods: An online global survey was disseminated using Survey Monkey® between 4th August 2020 and 17th November 2020. A global network of collaborators facilitated participant recruitment. Data were collated anonymously with informed consent and analysed using univariate and adjusted multivariable analyses. Results: Seven hundred and forty-three doctors of median age 27 (IQR: 25-30) were included with the majority (56.8%, n = 422) being male. Two-thirds of doctors were in a training post (66.5%, n = 494), 52.9% (n = 393) in a surgical specialty and 53.0% (n = 394) in low- and middle-income countries. Sixty-nine point two percent (n = 514) reported an overall perceived negative impact of the COVID-19 pandemic on their training. A significant decline was noted amongst non-virtual teaching methods such as face-to-face lectures, tutorials, ward-based teaching, theatre sessions, conferences, simulation sessions and morbidity and mortality meetings (P ≤ .05). Low or middle-income country doctors' training was associated with perceived inadequate supervision while performing invasive procedures under general, local or regional anaesthetic. (P ≤ .05). Conclusion: In addition to the detrimental impact of the COVID-19 pandemic on healthcare infrastructure, this international survey reports a widespread perceived overall negative impact on medical and surgical doctors' training globally. Ongoing adaptation and innovation will be required to enhance the approach to doctors' training and learning in order to ultimately improve patient care.
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Full thickness skin graft versus split thickness skin graft in paediatric patients with hand burns : systematic review and meta-analysisOur objective was to compare the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. A systematic review and meta-analysis were carried out in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, and an electronic search was conducted to identify all Randomised Controlled Trials and non-randomised studies comparing the outcomes of full thickness skin grafts versus split thickness skin grafts in paediatric hand burn patients. Primary outcomes included development of post-graft contracture and the necessity for surgical release. Secondary outcomes consisted of evaluation of function, cosmesis and colour, scar and feeling, hair growth, and other complaints. For the analysis, fixed effects modelling was applied. Results: ten non-randomised trials with a total of 532 grafts were found. Full thickness skin grafts exhibited a statistically significant decrease in the development of post-graft contracture (Odds Ratio [OR] = 0.35, P = 0.0001) and later surgical releases (OR = 0.06, P = 0.00001). For secondary outcomes, full thickness skin grafts outperformed split thickness skin grafts in post-operative functional ability. However, split thickness skin grafts, showed to be superior in scar, aesthetic, and colour assessments, and less hair growth was observed for split thickness skin grafts. No significant difference was seen in sensation and donor or recipient site complaints. Overall, full thickness skin grafts are a better alternative for paediatric hand burns than split thickness skin transplants because they are linked with reduced post-graft contracture and the requirement for surgical release.
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Inferior oblique anterior transposition versus myectomy for inferior oblique overaction : systematic review and meta analysisThe objective of this study was to compare the outcomes of inferior oblique anterior transposition (IOAT) versus inferior oblique myectomy (IOM) in patients with primary inferior oblique overaction (IOOA) or secondary IOOA to superior nerve palsy. A systematic review and meta-analysis were performed using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines and an electronic search was conducted to identify studies comparing IOAT versus IOM for IOOA. Residual inferior oblique function, reduction in hypertropia and post-operative complications were identified as primary outcomes. Secondary outcomes included superior oblique function, head tilt improvement, effect on the contralateral eye, operation time and macular changes. The analysis was based on fixed or random-effects modelling. Eleven studies enrolling 729 patients were identified. Inferior oblique function was not significantly different between both interventions, namely the elimination of IOOA (Odds Ratio[OR] = 0.97, P = 0.97), reduction in IOOA (Mean Difference[MD] = -0.06, P = 0.68), post-operative inferior oblique under-action (OR = 1.06, P = 0.83) and residual overaction (OR = 0.71, P = 0.15). Similarly, no significant difference was noted between both groups in reducing hypertropia. Regarding post-operative complications, no significant difference was observed, including the incidence of anti-elevation syndrome (P = 0.10). No significant difference was noted regarding superior oblique function, improvement in head tilt, effect on the contralateral eye and macular changes, although surgical time was shorter in the IOM group. In conclusion, IOAT and IOM are both effective surgical procedures in the management of IOOA as they produced comparable outcomes in the improvement in hypertropia, post-operative inferior oblique function and incidence of complications.
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Extracorporeal shockwave therapy versus ultrasound therapy for plantar fasciitis : a systematic review and meta-analysisThe objective of this study was to compare the outcomes of extracorporeal shockwave therapy (ESWT) versus ultrasound therapy (UST) in plantar fasciitis. A systematic review and meta-analysis were performed. An electronic search identifying studies comparing ESWT and UST for plantar fasciitis was conducted. Primary outcomes were morning and activity pain, functional impairment, and the American Orthopaedic Foot and Ankle Society (AOFAS) scale score. Secondary outcomes included the fascial thickness, primary efficacy success rate, activity limitations, pain intensity, and satisfaction. Seven studies enrolling 369 patients were identified. No significant difference was found between ESWT and UST for functional impairment (mean difference [MD] = -2.90, P = 0.22), AOFAS scale score (MD = 35, P = 0.20), and pain in the first steps in the morning (MD = -4.72, P = 0.39). However, there was a significant improvement in pain during activity for the ESWT group (MD = -1.36, P = 0.005). For secondary outcomes, ESWT had improved results in terms of primary efficacy success rate, activity limitations, and patient satisfaction. The reduction of plantar fascia thickness showed no significant difference. Pain intensity after treatment had varied results amongst included studies. In conclusion, ESWT is superior to UST for plantar fasciitis as it improves pain activity and intensity, primary efficacy success rate, and activity limitations.