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Issue #3: September 7th, 2022

“Do you not see how necessary a world of pains and troubles is to school an intelligence and make it a soul?”.

--John Keats


HAPPENINGS THIS MONTH:

  • Thank you to everyone who applied to be writers. We had a large group who were eager to join us.

  • This month’s surgeon spotlight is Dr. Olga Jonasson. She was a force to reckon with.

  • Do you have any surgical research you would like us to showcase? Email us and let us spread the word.

Bob Marley once said, “One good thing about music, when it hits you, you feel no pain.” Could that same logic apply to post-operative care? Patients undergoing surgery commonly feel anxious due to the surgery itself, anesthesia, and/or lack of familiarity with the operating room environment. Anxiety can lead to an autonomic response which, if exacerbated, can affect patients’ health and recovery. Music is a nonpharmacologic modality that can be used to change feelings of discomfort into more pleasant ones.

In this randomized control trial, the authors sought to determine whether or not music had an impact on preoperative anxiety, hemodynamic parameters (e.g., HR, RR, BP), and overall satisfaction in patients undergoing orthopedic surgeries under spinal anesthesia. The study included 70 randomized patients scheduled to undergo lower limb orthopedic surgeries under spinal anesthesia. The 35 patients in the intervention group listened to standard relaxation music, and the 35 patients in the control group listened to a recording of operating room noises through noise-canceling headphones. For both groups, the primary measurements were intraoperative hemodynamic parameters, preoperative anxiety, sedation score, and patient satisfaction. In the intervention group, patients’ heart rates were significantly lower at 10 minutes of assessment (p=0.003) compared with the control group, and the difference was highly significant (p<0.001) for the remaining duration (120 minutes). The intervention group’s respiration rates were also significantly lower than those of the control group (p=0.005). The sedation score was lower for the intervention group for the rest of the intraoperative assessment and at postoperative time (p<0.001).

Additionally, patients in the intervention group were more satisfied with their surgery outcomes than those in the control group.

In conclusion, music can be effective in allaying patient anxiety, stabilizing hemodynamics, and improving patient satisfaction in patients undergoing surgery. However, the study’s results could be affected by outcome bias as the patients were necessarily aware of which treatment group they were in. The results could also have been influenced by the study’s small sample size and confounding factors such as chronic diseases, patients’ socioeconomic status, and patients’ education level. Therefore, future studies need to investigate music’s effects on a surgery patient population large enough to assess the influence of various background factors.


One of the most common complications of any surgery is incisional hernia (IH), which can be difficult to repair and manage in the long run. The reported incidence of IH after colorectal surgery varies up to 40%, so certain surgical techniques are regularly employed for the prevention of IH. One of the techniques utilized for abdominal repair is the “Hughes Repair”. To put it simply it “combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture” (1). In this study, the clinical and cost effectiveness of the Hughes abdominal closure compared to standard closer are investigated. The primary outcome measured in this multicenter, single-blinded RCT was the incidence of IH at one year following surgery for colorectal cancer. 802 patients with colorectal cancer requiring a midline abdominal incision were randomized to receive either the Hughes abdominal closure or the standard closure in a 1:1 ratio. The standard closure involves closing the layers of the abdominal wall (except skin) with non-absorbable suture in a continuous, linear manner. Compared to the standard closure, the Hughes closure employs a “near and far” approach, which combines vertical and horizontal mattress sutures.

The primary outcome was not statistically significant. Although the Hughes closure had lower rates of IH incidence compared to standard closure at both the 1-year and 2-year marks following surgery, the difference was not significant. Patients with prior abdominal surgeries and current hernias were included in both study arms, which could be a potential confounding factor for lack of statistical significance. Additionally, the closures were performed by various surgeons. Thus, results may have been impacted by the difference in surgical technique, depending on which surgeon performed the operation. Repeating this study after excluding those with prior colorectal surgeries and current incisional hernias with the standardization of surgeon technique may be desirable to provide a more concrete conclusion.

  1. Cornish, J., Harries, R.L., Bosanquet, D. et al. Hughes Abdominal Repair Trial (HART) – Abdominal wall closure techniques to reduce the incidence of incisional hernias: study protocol for a randomized controlled trial. Trials 17, 454 (2016).

With over 20 million groin hernia operations performed worldwide annually, complications, such as surgical site and mesh infections, remain a common problem postoperatively. Guidelines have been developed in hopes to reduce rates of postoperative complications; however, these guidelines focus on surgical technique and activity restrictions, not patient optimization or selection. The National Veterans Administration Surgical Risk Study established preoperative serum albumin levels as a strong correlate to postoperative outcomes. Hypoalbuminemia (defined as serum albumin < 3.5 g/dL) has been used as a malnutrition marker, and is associated with increased mortality, postoperative complications, and resource use. In this study, researchers were interested in whether low serum albumin levels would be associated with greater rates of postoperative mortality, complications, and readmission. An additional interest lay in whether the poor nutrition status increased the duration of hospital stay after groin hernia repair.

This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program data from 2006 to 2019 and evaluated perioperative outcomes and 30-day morbidity and mortality. Inclusion criteria for this study included adults (> 18 years old) who underwent open or laparoscopic repair of inguinal or femoral hernias. The researchers stratified participants into four different categories based on the preoperative serum albumin levels: severe hypoalbuminemia (<2.5 g/dL), moderate hypoalbuminemia (2.5 to < 3.0 g/dL), mild hypoalbuminemia (3.0 to < 3.5 g/dL), and normal albumin (> 3.5 g/dL).

Out of the 261,052 patients who met inclusion criteria, 0.3% (688 patients) had severe, 1.1% (2,973 patients) had moderate, and 7.4% (19,364 patients) had mild hypoalbuminemia, whereas 91.2% (238,027 patients) had normal preoperative albumin levels. It was noted that those in the that a higher number of older women were in the severe category, and had a higher prevalence of incarcerated and strangulated groin hernias that faced longer operative times. A multivariable regression showed that those with severe, moderate, and mild hypoalbuminemia, compared with normal albumin levels, were associated with significantly higher odds of 30-day mortality. Lastly, a stepwise increase in the risk of complications (such as septic shock bleeding and pneumonia), length of stay, and 30-day readmission was observed with decreasing levels of serum albumin. The authors concluded that preoperative serum albumin remains a useful predictor of postsurgical outcomes and can be utilized in the optimization of malnourished patients seeking groin hernia repairs. Although the methodology of this study is sound, a limitation to this study, as acknowledged by the authors, is the use of a validated imputation method to account for missing serum albumin values.



In surgery, there is some concern regarding the possibility of "rebound refills" due to inpatient stays becoming shorter and given standardized opioid prescriptions on discharge. In this non-randomized, prospective quality improvement study, researchers aimed to compare the rate and volume of opioid prescription refills in surgical patients discharged based on different days post-operatively.

The postoperative days (POD) used were: 2-3, 4-7, and 8+. Patients were put into cohorts by POD of discharge: POD 2-3 (“short”), POD 4-7 (“intermediate”), and POD 8+ (“long”). The study involved 409 patients when the results were analyzed. Through the stratification processes, 37.7% (154) were discharged under the label of "short", 43.0% (176) were discharged under the label of intermediate, and 19.3% were discharged under the label of "long" (79). The concern that patients with shorter stays were associated with a possible increase in opioid refills was diminished as patients with “short” stays seemed to not have increased rates of refilling at 11.7% compared to 18.2% for intermediate POD and 19.0% for long POD with P = 0.193. "Rebound refills" do not seem to be a concern based on these results, but there is room for more analysis with study methods outside of a retrospective study.



SURGEON SPOTLIGHT OF THE MONTH

Olga Jonasson, MD

1934-2006




In this issue, we will take a look at the legacy of Dr. Olga Jonasson, a sincere patient advocate, a pioneer for women in surgery, and “the first” for a multitude of positions. We all remember the mentors who shaped us into who we are or how we see ourselves in medicine. A strong mentorship and role model are pivotal for the careers of many physicians, especially in the field of surgery. In an environment where advocacy is needed for not only patients, but upcoming and rising physicians, Dr. Jonasson was more than just an accomplished surgeon.

To start off the recognition of her decorated experience, Dr. Jonasson was the first woman to be appointed as the chief of surgery at a major hospital, the first woman to lead an academic department of surgery, the first female surgeon to serve as the Medical Director in a major department of the American College of Surgeons, the first to perform kidney transplant surgery in the state of Illinois, and the founding member of the National Tissue Typing and Histocompatibility Organization.


As a medical student at the University of Illinois College of Medicine, she was one of the first few women who sought to join the field of surgery during a time when surgery was especially unwelcoming for women physicians. She completed her residency at the University of Illinois and pursued a postgraduate fellowship at Walter Reed Institute of Research in Washington D.C., where she completed her research in immunochemistry under the mentorship of Dr. Elmer Becker. She then completed a second fellowship at Massachusetts General Hospital in transplantation immunobiology under Dr. Henry Winn and Dr. Paul Russell. From 1967 to 1987, Dr. Jonasson served as a faculty member of the surgical department at the University of Illinois where she set up a statewide histocompatibility-testing laboratory for donor -recipient matching, which marks her as a pioneer in the field of clinical transplantation and histocompatibility. She was named chief of surgery at Cook County Hospital in 1977 and became the chair and professor for surgery at Ohio State University in 1987.

Dr. Jonasson returned to Chicago in 1993 for her appointment at her senior position at the American College of Surgeons, where she contributed to a large number of educational programs and research in surgery. In her later career, she became a member of the editorial boards of Annals of Surgery and the Journal of the American College of Surgeons. She was also a reviewer for the Journal of the American Medical Association and the New England Journal of Medicine. Dr. Jonasson also held influential positions in many surgical societies and the board of directors of the American Board of Surgery in addition to the Accreditation Council for Graduate Medical Education.

In her career, Dr. Jonasson mentored many young physicians and residents, many of whom hold influential positions within the medical and surgical communities today. In many accounts of her, she was widely honored by her students and mentees for her immense support and influence for her trainees. She was an advocate for the surgeons training under her, especially young female residents at a time when the culture of surgery was unforgiving for women and their commitments to their families. In addition, Dr. Jonasson widely supported residents and young surgeons of all genders and backgrounds by using her influence in providing opportunities as speakers or guests at national conferences for her trainees. She recognized the need for encouragement and support within the new generation of surgeons to the establishment of influential leaders of the future of medicine.

In the memories of many who knew her, some of the best contributions of Dr. Jonasson were more than her titles and awards, although she was certainly not short of her well-deserving honors. She was recounted fondly by many leaders within the fields of surgery, and it was her support and encouragement that led to the development of many distinguished surgeons and subsequent advancement in surgery.


Sources:

  1. https://www.youtube.com/watch?v=YVqEOHIC1Rg&ab_channel=AmericanCollegeofSurgeons

  2. "Olga Jonasson, MD, FACS (1934-2006)". American College of Surgeons. Retrieved October 29, 2019.

  3. Husser W, Neumayer L. Olga Jonasson, MD: Surgeon, Mentor, Teacher, Friend. Ann Surg. 2006;244(6):839-840. doi:10.1097/01.sla.0000248100.13289.c0

  4. Bartholomew, A.; Ascher, N.; Starzl, T. (August 1, 2007). "TRIBUTE: Dr. Olga Jonasson Born in Peoria, Illinois, August 12, 1934 Died in Chicago, Illinois, August 30, 2006". American Journal of Transplantation. 7 (8): 1882–1883. doi:10.1111/j.1600-6143.2007.01872.x. ISSN 1600-6143. PMID 17578502.

  5. https://www.womensurgeons.org/page/AboutOlgaJonasson?


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