Surgery

Cost Analysis of Thoracic Endovascular Aortic Repair in Type B Aortic Dissection: How Much Does Quality Cost? (2023)

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Type of publication:Journal article

Author(s):Bashir M; Jubouri M; *Patel R; Geragotellis A; Tan SZ; Bailey DM; Mohammed I; Velayudhan B; Williams IM

Citation:
Annals of Vascular Surgery. 94 (pp 38-44), 2023. Date of Publication: August 2023.

Abstract:Introduction: Aortic dissection (AD) is a life-threatening medical emergency that affects an estimated 3-4 people per 100,000 annually, with 40% of cases classified as type B AD (TBAD). TBAD can be further classified as being complicated (co-TBAD) or uncomplicated (un-TBAD) based on the presence or absence of certain features such as malperfusion and rupture. TBAD can be managed conservatively with optimal medical therapy (OMT), or invasively with open surgical repair (OSR) or thoracic endovascular aortic repair (TEVAR), depending on several factors such as type of TBAD and its clinical acuity. The cost-effectiveness, or cost-benefit profile, of these strategies must be given equal consideration. However, TBAD studies featuring cost analyses are limited within the literature. Aims: This narrative review aims to address the gap in the literature on cost effectiveness of TBAD treatments by providing an overview of cost-analyses comparing OMT with TEVAR in un-TBAD and TEVAR with OSR in co-TBAD. Another aim is to provide a market analysis of the commercially available TEVAR devices. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus and EMBASE to identify and extract relevant studies. Results: Several TEVAR devices are available commercially on the global market costing $12,000-19,495. Nevertheless, the Terumo Aortic RELAY® stent-graft seems to be the most cost-effective, yielding highly favourable clinical outcomes. Despite the higher initial cost of TEVAR, evidence in the literature strongly suggest that it is superior to OMT for un-TBAD on the long-term. In addition, TEVAR is well established in the literature as being gold-standard repair technique for co-TBAD, replacing OSR by offering a more optimal cost-benefit profile through lower costs and improved results. Conclusion: The introduction of TEVAR has revolutionised the field of aortovascular surgery by offering a highly efficacious and long-term cost effective treatment for TBAD.

Fate and Consequences of the False Lumen After Thoracic Endovascular Aortic Repair in Type B Aortic Dissection (2023)

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Type of publication:Journal article

Author(s):Jubouri M; *Patel R; Tan SZ; Al-Tawil M; Bashir M; Bailey DM; Williams IM

Citation:Annals of Vascular Surgery. 94:32-37, 2023 Aug.

Abstract:Background: Type B aortic dissection (TBAD) occurs due to an entry tear in the intimal layer of the aorta distal to the origin of the left subclavian artery where blood enters the newly formed false lumen (FL) and extends distally or proximally to form a dissection over an indeterminate length of the aorta which, over time, may eventually rupture. Thoracic endovascular aortic repair (TEVAR) aims to seal off the entry tear proximally with the stent-graft, occluding the origin of the dissection and excluding the FL. Nevertheless, in some cases, the perfusion to the FL is maintained, hindering the aortic remodelling process and increasing the risk of aneurysmal degeneration and rupture, particularly in the abdominal aorta where evidence suggest that remodelling is slower. This review examines the long-term effects of a patent or partially thrombosed FL on clinical outcomes following TEVAR in TBAD, also highlighting the pathological processes behind negative aortic remodelling. Another aim of this review is to provide an overview and appraisal of the currently available techniques for managing a patent or partially thrombosed FL to prevent long-term morbidity occurring. Methods: A comprehensive literature search was performed using several search engines including PubMed, Ovid, Google Scholar, Scopus, and Embase to identify and extract relevant studies. Results: Evidence in the literature show that a partially thrombosed FL is more dangerous than a patent FL due to the occlusion of the distal re-entry tears, impeding outflow and increasing mean arterial and diastolic pressures, whereas the latter is decompressed via distal re-entry sites. FL thrombosis and satisfactory remodelling is sometimes achieved in as few as 40% of patients after TEVAR due to the maintained perfusion of the FL either at the level of the thoracic or abdominal aorta. However, although the thoracic aorta is predominantly covered by the TEVAR stent-graft, poorer remodelling and more dilation is seen in the abdominal aorta. Several techniques are available to embolize the FL, including the Provisional Extension to Induce Complete Attachment, Stent Assisted Balloon Induced Intimal Disruption and Relamination in Aortic Dissection Repair, candy-plug, and Knickerbocker techniques. Conclusions: The management of TBAD is invariably TEVAR to seal off the proximal entry tear while extending the repair distally to completely exclude the FL. A risk of aortic wall dilatation distal to TEVAR stent-graft remains; hence, regular monitoring and accurate imaging are essential. At present, a patent FL can be treated using a range of different endovascular techniques.

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Early Cholecystectomy in the Ageing Population (2022)

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Type of publication:
Conference abstract

Author(s):
*Sturges P.; *Gupta A.; *Rashid U.; *Rupasinghe S.N.; *Adjepong S.; *Parampalli U.; *Kirby G.C.; *Jain R.K.; *Rink J.; *Riera-Portell M.; *Pattar J.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi67), 2022. Date of Publication: September 2022.

Abstract:
Background: The age group of patients presenting acutely with biliary pathology is rising and gallstone disease can no longer be said to be a disease of the young. The World Health Organisation classifies those aged 65 and over as elderly. Early cholecystectomy is accepted as a safe and effective method of managing acute biliary pathology, reducing further admissions, and reducing in-hospital stays. Our unit does not use age as barrier but uses performance status and co-morbidity to identify potential candidates for cholecystectomy. Method(s): Patients over the age of 65 who underwent acute cholecystectomy (AC) via the emergency cholecystectomy lists, were audited from 31st December 2019 to 31st June 2021. Patient demographics, co-morbidities and surgical factors were recorded. The primary outcome measures were in-hospital stay and re-admission, secondary outcomes were complications and perioperative mortality. Result(s): 41 elderly patients underwent AC during the audit period, (Female 56%, Male 44%). 30 patients had acute cholecystitis (73%). The median inpatient stay following surgery was 2 days (range 2-5 days) and the median admission to surgery time was 6 days (range 5-12 days). Three patients had a subtotal cholecystectomy. There were 3 complications from surgery which were all between a Clavien-Dindo score of 2 and 3. There were 3 immediate post-operative readmissions, with one 30-day mortality from ERCP pancreatitis and not from the operation. Conclusion(s): Early cholecystectomy appears to be a safe and effective treatment for this group of patients and based on this evidence we should continue to offer this treatment to patients irrespective of age.

The Surgical Trainee Perception of the Operating Room Educational Environment (2022)

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Type of publication:
Conference abstract

Author(s):
Rupani N.; Evans A.; *Iqbal M.

Citation:
British Journal of Surgery. Conference: ASiT Surgical Conference 2022. Aberdeen United Kingdom. 109(Supplement 6) (pp vi9-vi10), 2022. Date of Publication: September 2022

Abstract:
Aim: Limited hours and service provision are diminishing training opportunities for surgical trainees. It is therefore imperative to maximise each educational event in theatre. The Operating Room Educational Environment Measure (OREEM) evaluates each component of the theatre learning environment; however, it has not been validated in higher surgical trainees in England. We aim to validate the OREEM and evaluate surgical trainees' objective perspectives of the current operating room educational environment in one region. Method(s): Data was collected over one month from surgical trainees within Health Education Thames Valley using an online questionnaire consisting of: demographic data; the OREEM; a global satisfaction score. Result(s): 54 trainees participated. The OREEM had good internal consistency (alpha=0.906, variables=40) and unidimensionality. Mean OREEM score was 79.16%. Areas for improvement included better learning opportunities (72.9%) and pre/post-operative teaching (70.4%). Trainees were most satisfied with the level of supervision and workload (82.9%). No differences between gender (p=0.535) or hospital type (p=0.099) were demonstrated. The learning environment favoured senior trainees (p=0.017). There was a strong correlation between OREEM and the global satisfaction score (p<0.001). Conclusion(s): The OREEM was shown to be a reliable measure of the educational environment in theatre. It can be used to identify areas of improvement and as an audit tool. Suggested areas of improvement include facilitating pre- and post-operative teaching, reducing service provision, empowering trainees to plan lists, improving teamwork and using tools to optimise the educational value of each operation. There is a favourable attitude regarding the use of such improvement tools, especially for dissatisfied trainees.

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The positive impact of GIRFT (getting it right first time) on arthroplasty services in times of COVID-19 (2022)

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Type of publication:
Journal article

Author(s):
*Khan MM; *Khawar H; *Perkins R; Pardiwala A

Citation:
Annals of medicine and surgery, 2022 May; Vol. 77, pp. 103655

Abstract:
Background: This observational study evaluates the trends in arthroplasty services across National Health Services (NHS) following the COVID-19 pandemic about GIRFT (Getting it Right First Time) guidelines concerning National joint registry data (NJR data). Introduction: Since the advent of the COVID-19 crisis sustainability of elective arthroplasty services have become a burning question in NHS. Capacity crisis, unknown COVID-19 infection status, lack of ring-fenced beds, winter crisis, and unprecedented trauma have aggravated the situation further leading to severe impairment in quality of life and service provision. GIRFT guidelines have suggested a few solutions to this crisis and one of them is dividing the hospitals into Hot (trauma) and cold (elective) sites. Objectives: To review NJR data for pre and post COVID era along with the service structure of the hospital and test the hypothesis that whether redistribution of services into hot and cold sites is a possible solution for sustainable arthroplasty service across NHS. Methodology: A search was made into the NJR data from 2019, 2020, and 2021. The First 7 months were taken from each year I.e. From Ist January to 31st of July. A review of entries for arthroplasty was considered for all hospitals across England and Wales. Hospitals in Scotland, Ireland, and Isles of Man and major trauma centers were excluded. Any hospital that was recording at least 15 arthroplasty cases for 4 out of 7 months in 2021 was considered for review. A brief evaluation of their service structure was made, and hospitals were divided into Elective Centres (EC), Urgent Care Centres (UCC), and District General Hospitals (DGH) with in-house emergency services based on the information provided on their official website. In NJR data "completed operations by submission date" column was considered as a reference for data collection. A total of 1807, 1800, and 1810 were identified for 2019, 2020, and 2021 respectively. However, after applying inclusion criteria total number of entries was reduced to 120 hospitals. Data analysis and selection of hospitals were reviewed twice by two authors (MMK and AP) at different times to avoid any bias and reduce the chances of human error that can affect the outcome. A sub-analysis of data for the last 3 months (May, June, and July) was also performed for the respective years to get a better picture of arthroplasty trends and reduce the flaws of data interpretation. Ethical Approval and Data Consideration: A formal approval was taken from the NJR team in the UK before the data processing was initiated. The data source being used was available for public review on the NJR website. The team was happy for us to process and evaluate the data as per needs of our study. However, they requested a disclaimer and appreciation note for the members of the NJR team and hospital personnel across the UK that have made the provision of data and subsequent analysis leading to this study feasible. Results: 18 EC were included. The mean number of cases recorded per center was 427, 68, 348 for 2019, 2020, and 2021 respectively.20 UCC were identified. The mean number of cases performed were 213, 24, and 195 in 2019, 2020, and 2021 respectively. Similarly, 60 DGH with emergency services were included and the average number of cases recorded were 194, 27, and 166 for 2019, 2020, and 2021 respectively. Compared to 2019 out of 148 DGH in 2019 only 60 can provide a sustainable arthroplasty service signifying a drop of 40% in 2021 in the number of DGH which are contributing to elective services. Conclusions: The overall productivity of theatres in terms of arthroplasty services has decreased since the reinitialization of services in 2021. There is a need of hour to divide the services into hot and cold sites in terms of A/E and elective centers to provide safe and uninterrupted provision of arthroplasty services and address long waiting times for patients. Provisional of ring-fenced beds and arthroplasty wards is more technically feasible in centers that are not providing in-house emergency admission pathways or are specialist, dedicated elective centers

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Vesicourachal diverticulum (2022)

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Type of publication:Journal article

Author(s):*Mohamed G; *Ghani Z; *Lynn N; *Masilamani M; *Rowlands J

Citation:Annals of the Royal College of Surgeons of England. 104(9) (pp e255-e257), 2022. Date of Publication: 01 Nov 2022.

Abstract:We report a rare complication involving a healthy 45-year-old male patient who underwent an emergency laparoscopic appendicectomy for acute perforated gangrenous appendicitis. The patient was catheterised pre- procedure and the ports were inserted under vision. Upon completion of the procedure, a 15 Fr Robinson drain was left in the pelvis and was fed through the suprapubic port hole. Postoperatively the patient developed worsening, generalised abdominal pain and high output from the drain. The patient was re-catheterised but the computed tomography (CT) cystogram did not show any injury to the bladder. The drain fluid creatinine was noted to be raised (>4,000), indicating that urine was leaking into the drain. Conventional cystogram confirmed a contrast leak from the dome around the drain. Flexible cystoscopy confirmed that the drain had transversed the vesicourachal diverticula. The drain was pulled back and converted to a suprapubic catheter with the patient subsequently being discharged. Vesicourachal diverticula is a rare and often asymptomatic anomaly. When undertaking laparoscopic surgery, precautions should be taken to prevent port site injury such as catheterising the patient to ensure the bladder is empty and inserting the ports under direct vision. It is safer to visualise muscle rather than peritoneum during port insertion. In this case, the bladder diverticula was noticed extraperitoneally. Though the indirect CT cystogram reported no injury, this was unreliable as the bladder was not distended which led to the subtle injury being missed. Traditional cystogram should be considered in cases with a negative CT cystogram and a strong suspicion of bladder injury.

Patient Outcomes Related to In-Hospital Delays in Appendicectomy for Appendicitis: A Retrospective Study (2022)

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Type of publication:
Journal article

Author(s):
Claydon O; Down B; *Kumar S

Citation:
Cureus, 2022 Mar 10; Vol. 14 (3), pp. e23034

Abstract:
Background and objective In many hospitals, the availability of operating theatres and access to senior surgical and anaesthetic support diminish during night hours. Therefore, urgent surgery is sometimes postponed until the following morning rather than performed overnight, if it is judged to be safe. In this study, we aimed to determine if a delay in laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, correlated with worse patient outcomes. Our primary outcome was delayed discharge from the hospital. Our secondary outcomes were appendicitis severity, conversions, and postoperative complications. Methods We undertook a retrospective review of the medical records of patients who underwent laparoscopic appendicectomy for appendicitis at a UK district general hospital between 01/01/2018 and 30/08/2019. For each patient, clinical and demographic information, and time of hospital admission, surgery, and discharge were collected. Delayed discharge was defined as "time to discharge" >24 hours after surgery. Results A total of 446 patients were included in the study. In 137 patients (30.7%), "time to surgery" was under 12 hours; in 309 patients (69.3%) "time to surgery" was over 12 hours. Of note, 319 patients (71.5%) had a delayed discharge; 303 patients (67.9%) had complicated appendicitis, and 143 patients had severe appendicitis (32.1%). No statistically significant association between "time to surgery" and delayed discharge, appendicitis severity, conversion, or 30-day re-presentations was observed. Conclusion Time from admission to the start of appendicectomy did not affect patient outcomes. Short in-hospital delays in appendicectomy, such as an overnight delay, may be safe in certain patients and should be determined based on clinical judgement.

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The global level of harm among surgical professionals during the COVID-19 pandemic: A multinational cross-sectional cohort study (2022)

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Type of publication:Journal article

Author(s):Abouelazayem, Mohamed; Viswanath, Yirupaiahgari K S; Bangash, Ali Haider; Herrera Kok, Johnn Henry; Cheruvu, Chandra; Parmar, Chetan; Atici, Semra Demirli; Yang, Wah; Galanis, Michail; Di Maggio, Francesco; Isik, Arda; *Bandyopadhyay, Samik Kumar

Citation:Surgery; Mar 2022 [epub ahead of print]

Abstract:BACKGROUND Health care workers, including surgical professionals, experienced psychological burnout and physical harm during the coronavirus 2019 pandemic. This global survey investigated the coronavirus 2019 pandemic impact on psychological and physical health.
METHODS We conducted a global cross-sectional survey between February 18, 2021 and March 13, 2021. The primary outcome was to assess the psychological burnout, fulfillment, and self-reported physical level of harm. A validated Stanford Professional Fulfilment Index score with a self-reported physical level of harm was employed. We used a practical overall composite level ofharm score to calculate the level of harm gradient 1-4, combining psychological burnout with self-reported physical level of harm score.
RESULTS A total of 545 participants from 66 countries participated. The final analysis included 520 (95.4%) surgical professionals barring medical students. Most of the participants (81.3%)were professionally unfulfilled. The psychological burnout was evident in 57.7% and was significantly common in those <50 years (P = .002) and those working in the public sector (P = .005). Approximately 41.7% of respondents showed changes in the physical health with self-remedy and no impact on work, whereas 14.9% reported changes to their physical health with <2 weeks off work, and 10.1% reported changes in physical health requiring >2 weeks off work. Severe harm (level of harm 4) was detected in 10.6%, whereas moderate harm (level of harm 3) affected 40.2% of the participants. Low and no harm (level of harm 2 and level of harm 1) represented 27.5% and 21.7%, respectively. CONCLUSION Our study showed that high levels of psychological burnout, professional unfulfillment, work exhaustion, and severe level of harm was more frequent in younger professionals working in the public sector. The findings correlated with a high level of harm in surgical professionals impacting surgical services.

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Learning curves in minimally invasive pancreatic surgery: a systematic review (2022)

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Type of publication:Systematic Review

Author(s):Fung, Gayle; Sha, Menazir; Kunduzi, Basir; Froghi, Farid; *Rehman, Saad; Froghi, Saied

Citation:
Langenbeck's Archives of Surgery. 407(6) (pp 2217-2232), 2022. Date of Publication: September 2022.

Abstract:BACKGROUND The learning curve of new surgical procedures has implications for the education, evaluation and subsequent adoption. There is currently no standardised surgical training for those willing to make their first attempts at minimally invasive pancreatic surgery. This study aims to ascertain the learning curve in minimally invasive pancreatic surgery.
METHODS A systematic search of PubMed, Embase and Web of Science was performed up to March 2021. Studies investigating the number of cases needed to achieve author-declared competency in minimally invasive pancreatic surgery were included.
RESULTS In total, 31 original studies fulfilled the inclusion criteria with 2682 patient outcomes being analysed. From these studies, the median learning curve for distal pancreatectomy was reported to have been achieved in 17 cases (10-30) and 23.5 cases (7-40) for laparoscopic and robotic approach respectively. The median learning curve for pancreaticoduodenectomy was reported to have been achieved at 30 cases (4-60) and 36.5 cases (20-80) for a laparoscopic and robotic approach respectively. Mean operative times and estimated blood loss improved in all four surgical procedural groups. Heterogeneity was demonstrated when factoring in the level of surgeon's experience and patient's demographic.
CONCLUSIONS There is currently no gold standard in the evaluation of a learning curve. As a result, derivations are difficult to utilise clinically. Existing literature can serve as a guide for current trainees. More work needs to be done to standardise learning curve assessment in a patient-centred manner.

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