Surgical Technology International
44th Edition
July 2024 - ISSN:1090-3941
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Risk Factors for Microscopic Disease Positivity at Ileocolic Resection Margins for Crohn’s Disease
Adam Truong, MD, Jino Chough, BS, Karen N Zaghiyan, MD, FACS, FASCRS, Associate Professor, Phillip R Fleshner, MD, FACS, FASCRS, Professor, Cedars-Sinai Medical Center, Los Angeles, California
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Introduction: Interest in microscopic margin positivity during surgical resection of medical-refractory Crohn’s disease has been renewed with multiple recent studies showing an association between microscopic margin positivity with disease recurrence. Our aim was to determine risk factors for microscopic margin disease positivity following ileocolic resection (ICR).
Materials and Methods: A prospectively-maintained database of patients with Crohn’s disease undergoing ICR at a tertiary-referral center was queried. Margin positivity was defined as the presence of cryptitis, erosion, transmural inflammation with lymphoid aggregates, or architectural distortion at either ileal (proximal) or colonic (distal) margins.
Results: Amongst 584 patients, 97 patients had a positive microscopic margin (17%) of which 46% had a positive proximal margin, 17% had a positive distal margin, and 13% had both positive and distal margins. Using multivariable logistic regression analysis, index ICR was associated with less odds of positive margin (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.24-0.89, p=0.02), and granuloma presence was associated with increased odds (OR 2.26, 95% CI 1.23–4.21, p=0.01).
Conclusion: We found that repeat ileocolic resection and granuloma presence were predictors of microscopic margin disease.
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Decreasing Perioperative Opiate Use During Pancreaticoduodenectomy Using Transversus Abdominus Plane Blocks: A Review of the Literature
Carla R. Edgley, BSc (Hons) , University College Dublin, Belfield, Dublin, Ireland, Jorge G. Zarate Rodriguez, MD, Chet W. Hammill, MD, Associate Professor , Washington University School of Medicine, St. Louis, Missouri
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Background: Pancreatoduodenectomy is a highly complex surgical procedure associated with high postoperative morbidity and mortality. Treatment of postoperative pain is crucial to preventing chronic pain and further complications. Opioids are the leading treatment modality for acute postoperative pain for all surgical procedures in the US, contributing to the opioid epidemic, a crisis causing death and lifelong impairment in many patients. Multimodal analgesia techniques, such as the transversus abdominis plane (TAP) block, are suggested to reduce perioperative opioid usage. This exploratory literature review aims to investigate the use of TAP block in postoperative pain and opioid use in patients undergoing pancreatoduodenectomy.
Materials and Methods: A search strategy developed from Cochrane best practice recommendations was applied to a comprehensive search of PubMed, Scopus, and PsycINFO databases, yielding three articles of relevance in patients having pancreatic surgery.
Results: Previous research demonstrates TAP block efficacy in decreasing opiate consumption after major abdominal surgery; however, there is a paucity of data regarding opioid consumption in pancreatoduodenectomy patients.
Conclusion: Research in relation to TAP block analgesia is varied given the variety of approaches, techniques, and timing of the TAP block procedure. Future research should seek to elucidate the role of TAP blocks in reducing postoperative pain and opioid consumption in pancreatoduodenectomy patients.
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The Science of Stapling: Staple Form
Prachi Rojatkar, PhD, Anil K. Nalagatla, MS, Crystal D. Ricketts, PhD, Jeffrey W. Clymer, PhD, Emily Yosh, MD, Ethicon, Inc. Cincinnati, Ohio
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Surgical stapling has evolved significantly over time, with the primary goal of improving patient outcomes. This study describes the technological advancements in surgical stapling from the perspective of staple and cartridge design, assessing the impact of staple design when it changes from the traditional B form (also known as 2D staple form) to a three-dimensional form (known as 3D staple form). The change in configuration helps compress a larger surface area of the tissue. The 3D configuration is designed to optimize compression not only underneath each staple but also across staples and multiple staple lines, including both stapled and unstapled regions of the tissue. By achieving more evenly distributed compression throughout the staple line, there is potential for reduced leak paths. The study demonstrates that the 3D staple form in surgical stapling results in more evenly distributed compression. In the future, this advanced technology should seamlessly integrate into emerging systems such as the surgical robot, enabling continued progress in surgical instrumentation and ultimately in surgical care.
Twenty First Century Technological Toolbox Innovation for Transanal Minimally Invasive Surgery (TAMIS)
Alice Moynihan, MB, BCh, BAO, MRCS, Special Lecturer, Patrick Boland, MB, BCh, BAO, MRCS, Research Fellow, Ronan A Cahill, MD, FRCS, Professor, Centre for Precision Surgery, UCD, Dublin, Ireland
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Transanal minimally invasive surgery (TAMIS) is an effective procedure that plays an important role in the care of patients with significant rectal neoplasia and polyps including early-stage cancers. However, it is perhaps underutilised and under threat from both advanced flexible endoscopic procedures and proceduralists (who often act as gatekeepers for referral to colorectal surgeons), as well as from robotic surgery proponents. TAMIS advocates can learn and adopt practice insights from both these fields and incorporate available technological innovations building on the huge accomplishments already delivered in this area. Evolved practice through technology has the potential to offset current limitations regarding technical constraints and indeed patient selection (via artificial intelligence methods). Potential target areas for advances are considered in this review from different perspectives: (1) Access (2) Insufflation (3) Visualisation (4) Disease Characterization in situ, and (5) Tissue Handling and Suturing. While a bundle approach may be most useful, the advances for each component are potentially useful in their own right and could be applied without depending on the other practices detailed so that more accurate (and perhaps even numerically more) TAMIS procedures can be performed globally to improve patient care.
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Time to Operation and Mortality Risk in Elderly Patients with Intestinal Fistula: Not Too Early and Not Too Late
Rahim Hirani, MS, New York Medical College, Valhalla, New York, Abbas Smiley, MD, PhD, University of Rochester, Rochester, New York, Rifat Latifi, MD, FACS, FICS, FKCS, Professor, University of Arizona, Tucson, Arizona
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Introduction: This study aimed to ascertain the risk factors contributing to in-patient mortality in elderly patients 65 years and older who were admitted emergently, diagnosed with intestinal fistula, and underwent surgery.
Materials and Methods: Data were extracted from the National Inpatient Sample (NIS) spanning the years 2005–2014. Multivariable logistic regression and a generalized additive model (GAM) were employed to investigate predictors of mortality. Continuous variables are presented as mean values with standard deviations (SD).
Results: The study encompassed 34,853 patients with a mean age of 77.7 years—56.5% were female and 79.4% were White. Patients were categorized into three groups based on the time elapsed between admission and surgery: less than two days (17,761), two to three days (8,407), and more than three days (4,233). Mortality rates were 2.7%, 6%, and 6.1% for patients who underwent surgery within two to three days, within two days, and after more than three days of admission, respectively. Notably, the group that operated more than three days from admission experienced nearly double the hospital length of stay (12 days, SD: 7.2) compared to the other two groups (6.3, SD: 6 and 6.1, SD: 4.8). Furthermore, the association between mortality and time to operation, as indicated by the GAM model, revealed a significant non-linear relationship after adjusting for age, gender, race, zip code, hospital location, and comorbidities (p<0.001).
Conclusion: Elderly patients diagnosed with intestinal fistula should undergo operative treatment as soon as possible, once they are resuscitated. Delaying the operation more than three days after admission substantially increases the risk of mortality.
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Cadaveric Simulation in Rib Plating is Beneficial for Helping Surgical Trainees to Assimilate New Technologies
Dustin Nowotny MD, Assistant Professor, Kristen Reede MD, Mentor Ahmeti MD FACS, Associate Professor, University of North Dakota School of Medicine and Health Sciences, Fargo, ND
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Purpose: Rib fixation procedures are being performed more frequently as they have shown multiple advantages over traditional non-operative management in well-selected patients. We have developed a rib-fixation simulation on cadavers for use by surgical residents in attempt to improve their comfort, knowledge and ability to use this new technology.
Methods: Residents in years 3 through 5 of training attended a rib-fixation simulation course with cadavers. Trauma faculty and representatives of manufacturers of rib-fixation hardware participated. The simulation consisted of groups of residents reviewing anatomy and creating adequate exposure for the entire procedure. Each group created rib fractures in the cadaver, determined which materials were needed, and then performed the rib-fixation procedure. Following the simulation, we surveyed the residents to determine the impact of the structured cadaveric rib fixation-based course on their comfort level. The survey was performed using a four- and five-level Likert questionnaire. The results were analyzed using paired t-tests.
Results: Of the participating residents, 72% of residents had performed five or fewer rib-fixation procedures in their training in the first cohort, while in the cohort for the following year, 65% had performed 5-10 procedures. The simulation had a statistically significant benefit to the residents’ comfort level with rib plating (2.5 versus 3.6, p-value: 0.003). The greatest impact on the comfort level was seen in year 3 of training (2 versus 4, p-value 0.02). One hundred percent of residents found that having faculty and representatives present for the simulation was very helpful. The survey demonstrated that most residents gained new knowledge regarding the anatomy and technical dissection. In 20 of 25 encounters, residents strongly agreed that this simulation was beneficial for their surgical education, when used in addition to real operative experience. Every resident reported that they would recommend the simulation to younger resident classes.
Conclusion: Rib-fixation simulations on cadavers were beneficial for surgical residents’ self-assessed comfort level. The simulation increased residents’ knowledge, comfort, and ability to perform rib-fixation procedures. We have seen a significant increase in resident participation in these cases after simulation training. Based on these findings, we will continue to incorporate these simulations into our program’s curriculum.
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A Case Report of Neoadjuvant Gemcitabine Plus Cisplatin for Locally Advanced Unresectable Ampulla of Vater Carcinoma
Ryosuke Tsunemitsu, MD, Motoyasu Tabuchi, MD, Shinya Sakamoto, MD, Takehiro Okabayashi, MD, Mototsune Kakizaki, MD, Manabu Matsumoto, MD, Jun Iwata, MD, Yasuhiro Shimada, MD, Kochi Health Sciences Center, Kochi-City, Japan
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Introduction: Ampulla of Vater carcinoma (AVC) with para-aortic node (PAN) metastasis is considered unresectable and is equivalent to distant metastasis, contributing to poor outcomes.
Case presentation: A 60-year-old man was referred to our hospital and was diagnosed with an unresectable ampulla of Vater carcinoma that had metastasized to the para-aortic nodes. The patient received a systemic chemotherapy regimen comprising a combination of gemcitabine and cisplatin. Following five cycles of treatment, imaging studies revealed a significant reduction in the primary tumor and para-aortic node metastasis, rendering detection difficult. Pancreatoduodenectomy with para-aortic node dissection was performed as a radical surgery. Upon pathological examination, no residual tumors were identified in the resected specimen, indicating that the systemic chemotherapy achieved a complete pathological response. The postoperative course of the patient was uneventful, and he was discharged on the 25th postoperative day. The patient was followed up as an outpatient and remained stable without any recurrence for two months after surgery.
Conclusion: Neoadjuvant chemotherapy with gemcitabine and cisplatin was useful for downstaging the ampulla in patients with Vater carcinoma. This finding may help physicians manage patients with similar presentations.
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Sarcopenia As a Determinant Prognostic Factor After Surgery Among Patients with Colorectal Cancer
Michael Osseis, MD, MPH , Elia Kassouf, MD, Bilal Ramadan, MD, Rany Aoun, MD, Serge Kassar, MD, Houssam Dahboul, MD, Christian Mouawad, MD, Roger Noun, MD, Ghassan Chakhtoura, MD, Hôtel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon, Rhea Akel, MD, Hôtel-Dieu de France Hospital, Saint Joseph University, Beirut, Lebanon
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Introduction: Surgery for colorectal cancer (CRC) is not risk-free; therefore, preoperative evaluation must be done to predict and prevent surgical complications. Sarcopenia, a loss of muscle mass and function, was shown to be associated with surgical complications. Our study evaluates the effects of sarcopenia on short-term patient outcomes after CRC resection.
Materials and Methods: Our retrospective study included patients with histologically proven CRC between 2018 and 2020 who underwent surgical resection. Skeletal muscle mass (cm2) was evaluated on a preoperative CT scan at the level of L3 vertebrae then standardized using stature (m2) to obtain the skeletal mass index (SMI) (cm2/m2). Patients received proper adjuvant care if needed and were followed up 90 days post surgery. Descriptive statistics were presented in percentage for categorical variables and in mean for continuous variables. Multivariate was made by linear regression.
Results: 113 patients were included, and 15% were sarcopenic. A statistically non-significant association was found between sarcopenia and severe complications (grade III-IV) (23.53% in sarcopenic vs. 9.38% non-sarcopenic, p=0.02, multivariate p=0.675). Sarcopenia was not associated with anastomotic leakage, infectious complications, or ileus or intra-abdominal bleeding (p>0.05). In literature, some studies showed an association between sarcopenia and postoperative complications while others showed no relationship between the two. Most studies used SMI.
Conclusion: A non-statistically significant association was found between sarcopenia and postoperative complications in CRC patients. Sarcopenia does not predict postoperative severe complications, anastomotic leakage, infectious complications, or ileus or intra-abdominal bleeding. Emergent surgeries and age >60 years were associated with more postoperative complications.
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Thermal Ablation for Benign Thyroid Nodules and Papillary Thyroid Microcarcinoma
Daqi Zhang, MD, Professor, Hui Sun, MD, Professor, China-Japan Union Hospital of Jilin University; Jilin Provincial Key Laboratory of Surgical Translational Medicine, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Jilin, China, Anna Maria Ierardi, MD, Salvatore Alessio Angileri, MD, Giampaolo Carrafiello, MD, University of Milan, Milan, Italy, Francesco Frattini, MD, Istituto Auxologico Italiano IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico), Milan, Italy, Simone Mortellaro, MD, Arianna Ceriello, MD, Jerry Spisani, MD, Gianluca Donatini, MD, PhD, University of Milan, Milan, Italy, Gianlorenzo Dionigi, MD, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
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Ultrasound-guided minimally invasive thermoablative (MIT) therapies are a therapeutic option for selected patients with large, hypoenhancing, benign thyroid nodules that cause compression disorders or aesthetic discomfort. MIT, which does not require general anaesthesia, causes thermal necrosis of the treated nodule, which is reduced in size by 50 % without functional consequences, and is indicated for patients who are not too young or in the presence of anaesthesia-related risk factors or recurrence following thyroidectomy or refusal of surgery. For the above indications, MIT complements surgery but does not replace it; it must always be performed in centres and by surgeons with proven technical skills and clinical experience. Subject to appropriate informed consent, the treatment is short-duration, well-tolerated by the patient, safe, and non-invasive. It does not require anaesthesia and complications are rare and transient. MIT, and in particular laser-based procedures (TAL), can also be effective and safe for the treatment of potentially destructible papillary microcarcinoma, as shown by the limited but sufficient literature, including the most recent guidelines, which consider it to be a therapeutic alternative that requires a better understanding of its efficacy and safety.
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Vertical Mesh-Mediated Fascial Traction and Negative Pressure Wound Therapy: A Case Series of Nine Patients in General and Vascular Surgery
Thomas Mones, MD, Martin Pronadl, Dr. med., Maria-Hilf Hospital, Brilon, Germany Thomas Halama, Dr. med., Vasilena Chobanova, Dr. med., Thomas Halama, Dr. med., Thomas Nowroth, Dr. med.
St. Vinzenz-Hospital, Cologne, Germany
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Open abdomen (OA) is a well-established procedure for life-threatening illnesses such as septic peritonitis, abdominal compartment syndrome (ACS), and damage control surgery (DCS). Furthermore, in cases of life-saving aortic repair after perforation of abdominal aortic aneurysm, an OA is sometimes indicated. Definitive fascial closure (DFC) is one of the main goals during treatment to prevent further complications such as fistula formation and the development of an incisional hernia. In 2019, a new technique was introduced for OA using a device called fasciotens®Abdomen to apply dynamic traction to the abdominal wall through vertical mesh-mediated fascial traction (VMMFT). We present a case series including nine patients and show an algorithm for OA combining VMMFT and negative pressure wound therapy (NPWT).
Methods: Two patients in a vascular surgery unit and seven patients in an abdominal surgery unit with an OA were treated with VMMFT in combination with NPWT between September 2019 and June 2023.
Results: A DFC was achieved in seven of nine cases. The mean duration of OA was 9.6 ± 3.8 days, and fascial dehiscence at the beginning of OA was 14.2 ± 4.0 cm on average. Time to DFC after VMMFT was established was 6.2 ± 3.5 days (mean). No method-related complications occurred.
Conclusion: The standardized combination of VMMFT and NPWT gave positive results in achieving DFC in our heterogenic patient group. Following a strict treatment pathway as shown here seems to improve OA outcome. It represents a promising further development of mesh-mediated fascial traction for OA treatment.
