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Issue #4: October 12th, 2022

“The only means of strengthening one's intellect is to make up one's mind

about nothing -- to let the mind be a thoroughfare for all thoughts.”

--John Keats




HAPPENINGS THIS MONTH:

  • We are glad to publish our first issue with our new writers!

  • This issue we are introducing our new Surgical Subspecialty section which includes the following subjects: Urology, Cardiothoracics, Orthopedics, and Neurosurgery

  • Have any research to showcase? Please let us know and email us! Let us share it with your peers.

  • This month’s surgeon spotlight is Dr. Harvey William Cushings, a revolutionary doctor in both the field of surgery and internal medicine. You may have heard his name before…




Severe malnutrition is a rare but detrimental complication of bariatric surgery. Yet, there is very little data describing revisional surgery as an approach to this potentially life-threatening condition. A retrospective chart review was conducted for patients who underwent revisional surgery for malnutrition. The goal was to analyze the safety and efficacy of bariatric surgery amongst this malnourished group of patients. The initial bariatric surgeries amongst patients included 62% Roux-en-Y gastric bypass, 11% sleeve gastrectomy, 11% gastric band, 8% biliopancreatic diversion with duodenal switch, 6% mini-gastric bypass, and 2% jejunoileal bypass.

Of the 53 revisional operations performed, 37 were performed via an open approach. The remaining 16 were approached laparoscopically, of which 2 were converted to open. The most common revision was of the gastrojejunal anastomosis +/- resection of the Roux limb. Results showed a significant improvement in the manifestations of malnutrition after the revision surgery. Patients who underwent revisional bariatric surgery demonstrated a significant decrease in supplemental and total nutritional support requirement preoperative from 89% to 13.2%. With regards to complications in the early outcome phase (<30 days), there were no deaths. Additionally, the most common complication was an incisional surgical site infection. Limitations attributed to the study included the lack of prealbumin levels and shorter follow-ups. Nutritional status cannot be fully assessed without this information, which is a large variable that impedes the results. This study showed that while operative risks can be substantial, they are not prohibitive. Surgical revision should be considered for treating refractory cases of malnutrition after bariatric surgery as it is a relatively safe and effective option.




Although over 20 million people have recovered from COVID-19 in the US, many still suffer from medical problems such as pneumonia, respiratory failure, pulmonary embolism (PE), and deep venous thrombosis (DVT). The purpose of this study was to assess the variables seen when the patient underwent their elective operation relative to when they had COVID-19. The study population included those with a confirmed COVID-19 diagnosis via the first positive COVID-19 PCR test. Patients who underwent an operation were based on Current Procedural Terminology (CPT) codes with a select list of elective procedures. The study population was then divided into four groups; “peri-COVID-19” with surgery between 0-4 weeks after the COVID diagnosis, “early-post COVID-19” was 4-8 weeks, and “late-post COVID-19” which was 8 or more weeks after daignosis, and one control group. A total of 5,479 patients took part in the study with the most common operations being hysterectomy and knee arthroplasty with top comorbidities including obesity and hypertension. Those who underwent an operation closer to their first positive PCR test were found to be at an increased risk of post-operative pneumonia (adjusted odds ratio [aOR], 6.64; 95% confidence interval [CI]: 4.06-10.27), respiratory failure (aOR, 3.36; 95% CI: 2.22-5.10), PE (aOR, 2.73; 95% CI: 1.35-5.53), and sepsis (aOR: 3.67; 95% CI: 2.18-6.16). Those within the 4-8 wks were at mild increased risk (aOR: 2.44; 95% CI: 1.20-4.96), and those within the 8 weeks or more group were found to be at no increased risk of postoperative complications. However, there are many limitations to this study that can impact the results. First and foremost was its retrospective design. Other limitations include the inability to confirm whether the patients were symptomatic or asymptomatic at time of COVID diagnosis and the inability to pinpoint the exact COVID diagnosis date and time. Additionally, the study could not assess mortality rates at 30 or 90 day timeframes due to the research database not including the information. Such limitations need to be taken into account and redirected for further evaluation in order to fully grasp the surgical risks seen with COVID-19.





For the young adult, the terrors of a cancer diagnosis extend far past bodily harm. A cancer diagnosis at this stage can be debilitating in ways that people within other life stages cannot and do not comprehend. This study analyzed the emotional, psychological, and financial burden that oncological surgery places on young adults by utilizing a validated biopsychosocial distress screening tool (SupportScreen) on newly diagnosed cancer prior to surgery. The results were analyzed with logistic regression. Patients were classified as Young Adults (YA; less than 45 years) [n=573] and Older Adults (OA; over 45 years). Distress levels were compared and analyzed between the two groups. It is important to note that although education levels were similar between groups, the YA group was more likely to have lower income and were unmarried. Of the 4297 patients, the YA group demonstrated higher rates of emotional distress, fear of procedures (26.7% vs 22%, P=0.018) and anxiety (33.8% vs 27.4%, P=0.002). They were more likely to feel the pressures of financial distress when compared to the OA group (40.5% vs. 28%, P<0.001). In comparison to the OA group, the YA group was more worried about managing work and school, coordinating care, finding community resources, procedure side effects, changes to their physical appearance, and their risk of infertility. One needs to consider, however, the lower number of patients comprising the YA group, which consist of 13.3% of the total patients studied. The small sample group for YA group adds a kink to the representation of the study. It is true that cancer rates are lower in younger patients, however, that does not negate the requirement for a larger patient pool. But, one needs to take such results into consideration when addressing younger patients with regard to oncological surgery.





Laparoscopic or not, that is the question. Duodenal Atresia (DA) is a major cause of neonatal duodenal obstruction, and surgical management has evolved exponentially since it was first attempted in 1931. Previous single-center studies have shown inconsistent results when comparing laparoscopic vs open DA repairs. This retrospective cohort study investigated infants who underwent DA repair within the first week of life by using a large multi-institutional pediatric database. The purpose was to examine the 30-day post-operative outcomes between patients who underwent open vs laparoscopic repair. The outcomes assessed were total surgery time, length of hospital stay, supplemental nutrition discharge, and surgical complications. Amongst the 267 neonates evaluated, the results showed that laparoscopy was associated with an increase in total operative time by 65 minutes compared with open repairs. However, the laparoscopy was associated with a 5-day shorter hospital stay. There was no significant difference in post-surgical complications, safety, or nutrition between the two groups. Based on the data from the study, laparoscopy has comparable outcomes to open repair. And yet, amongst the patient population there were 233 (87.3%) underwent open repair while 34 patients (12.7%) underwent laparoscopic repair. One needs to consider the lower sample size for the laparoscopic group when interpreting the result. Though the shorter operative and recovery time make laparoscopic repair attractive, further studies need to be initiated to validate the benefit.


Subspecialties: Urology


Currently the definitive treatment for T1 renal masses is surgical management, but recent developments have expanded the use of Robot-assisted partial nephrectomy (RAPN) and laparoscopic partial nephrectomy (LPN) for complex renal tumors. Early in the development of these surgeries, suturing renorrhaphy (suturing the kidney) was considered indispensable for implementing homeostasis and stabilization of the urinary system. But the recent literature has introduced the possibility that damaging the vascular system of the kidney with such maneuvers will destabilize the patient’s renal function post-operatively. The omission of cortical suture renorrhaphy was developed in order to keep the renal parenchyma healthy. Studies have been varied on whether the RAPN vs the LPN approaches better when accounting for this feature. In this retrospective study, researchers compared the robot-assisted (CRO-RAPN) cortical-renorrhaphy-omitting partial nephrectomy and laparoscopic (CRO-LPN) cortical-renorrhaphy-omitting partial nephrectomy via the rates in completing three criteria: a negative surgical margin, warm ischemic time <25 min, and no complications of Clavien-Dindo grade III or higher until 3 months post-op. The outcomes evaluated include GFR, estimated blood loss, and the presence of negative complications. The patients were matched via Propensity Score matching.

Of the total 150 matched patients in pairs 210 patients were in the CRO-RAPN group and 81 patients were in the CRO-LPN group. The CRO-RAPN group was linked to a greater eGFR preservation rate six months after the operation (93% vs. 89%, P = 0.003), less total operation time (162 min vs. 212 min, P < 0.001), less warm ischemic time (13 min vs. 20 min, P < 0.001), and a smaller number of complications (3% vs. 16%, P = 0.001). Overall the CRO-RAPN group achieved a higher rate of the trifecta compared to the CRO-LPN group. This study establishes the possibility of leaning towards robotic surgery when utilizing cortical omitting renorrhaphy. However, one needs to take this information with a grain of salt. The smaller patient pool, reliance difference in group numbers, the steep learning curve for these complex procedures and setting within a single institution are amongst the many limitations attached to this study. Yet the benefits of robotic surgery coupled with the possibility of ensuring preserved kidney function post-op are highly advantageous and should attract more investigative intrigue.




Subspecialties: Cardiothoracics


Transaortic Morrow procedure is an invasive modality requiring a median sternotomy and transverse dissection of the ascending aorta to expose the interventricular septum. Currently, it is the golden standard for the treatment of Hypertrophic Obstructive Cardiomyopathy (HOCM), when it is resistant to medical management. But studies have introduced the use of a thoracoscopic transmitral myectomy with an anterior mitral leaflet extension (TTM-AMLE) in order to decrease the systolic anterior motion. This study analyzed 18 patients with HOCM and preoperative mitral regurgitation from systolic anterior motion receiving successful TTM-AMLE in order to assess the outcomes of the procedure.. On average these patients stayed 2.7 (1.4, 5.2) days in the ICU with only a few patients experiencing complications. A significant decrease was observed in the septum thickness (from 18.03 ± 3.02 mm to 11.91 ± 1.66 mm, p < .001) and proportion of systolic anterior motion (94.44% vs. 16.67%, p < .001), while improving physiologic function. The article suggests this approach to be safe and effective, but with such a small patient pool these conclusions are very preliminary. Longer follow ups would be more beneficial to add on to the study in order to validate the claims.



Subspecialties: Orthopedics


Anterior cruciate ligament (ACL) injuries affect quality of life and knee function of thousands of young people annually. Since the popularization of the double-bundle ACL reconstruction technique, several randomized clinical trials evaluating associated outcomes have been published. This randomized clinical trial evaluated the 5-year, disease-specific quality-of-life outcomes of patients treated for ACL deficiency with use of a patellar tendon, single-bundle quadruple-stranded hamstring, or double-bundle hamstring reconstruction. 745 patients screened and 330 were used for the study. Those with multiple ligament issues, previous surgery of the ligament, and connective tissue disease were excluded. Mean ACL-QOL scores increased significantly from baseline to 5 years for all groups (p < 0.0001). However, did not differ at 5 years among the groups (p = 0.548) Pivot shift grades at all time periods were similar among the groups. The proportions of patients with a pivot shift grade of at least 2 at 5 years demonstrated a trend in favor of patellar tendon reconstruction at 12% compared with 16% for hamstring tendon and 22% for double-bundle; (p = 0.149). The groups’ differences in post-surgical ROM was statistically insignificant. IKDC Grade showed there was a trend in favor of the patellar tendon group, with a normal and nearly normal IKDC grades: 87% compared with 82% for hamstring tendon, and 75% for double-bundle (p = 0.093). In conclusion, there was no significant difference in quality-of-life outcomes for ACL reconstruction. There was a trend toward a higher percentage of normal and nearly normal IKDC grades in the patellar tendon group compared with the hamstring tendon and double-bundle groups.


Subspecialties: Neurosurgery


Neurosurgery, whether general or pediatric, can be challenging due to differences in anatomy and physiopathology. 3D printing provides a possibility to create models based on imaging data in the hope of optimizing surgical planning and practice before the actual procedures. In this paper, the authors focus on demonstrating how 3D printing is used in pediatric neurosurgery. It focuses on its use in surgical planning for craniosynostosis reconstruction and training of budding pediatric neurosurgeons.

Craniosynostosis is the premature closure of one of more of the cranial sutures which will cause calvarial deformities in an infant. Prevalence is between 1 in 2100-2500. The pathology usually requires the use of multiple craniofacial and pediatric neurosurgeons in unison as well as many therapists. Because this condition is not seen commonly in neurosurgical practice, training in management is limited. Advanced knowledge is required in order to attain the best outcome as craniosynostosis, like all other surgical pathologies, can have a variable anatomical presentation. Creating a realistic model could be the key for well-rounded training.

Indeed, 3D printing has changed the game for this field by allowing doctors to hold the problem in their hands before even facing it in real life. Furthermore, practicing on models and rehearsing several times allows the actual procedure to be performed more smoothly and accurately. One more area that has had a huge impact is in the training of junior pediatric surgeons. Although this field is rapidly expanding both in quality and representation of actual human tissue, there are still some limitations in regards to the creation of high standard 3D models, however these limitations most likely will be resolved over time, expansion, practice and more innovation.

In conclusion, even though we may have a long way to go with 3D printing technology, this tool is already implemented in many US hospitals, allowing surgeons to understand and prepare for very complex procedures, increasing their confidence, techniques, and decision-making capacity; along with minimizing the risk of postoperative complications such as blood loss or rate of infections. In the future, this technology will certainly be a fundamental piece in the training of many junior surgeons, even senior ones, who are looking to further improve their skills.




SURGEON SPOTLIGHT OF THE MONTH


Harvey William Cushing, MD

April 8, 1869 – October 7, 1939 (aged 70 years old)


For this issue, we will take a look at Dr. Harvey Cushing’s contributions to the surgical arts and medicine. While his name may be familiar to most of us for his work towards Cushing’s disease and the Cushing reflex, Dr. Cushing was also the first official neurosurgeon. Because of his expertise and discoveries, neurosurgery was established as a surgical specialty within our medical system.

Dr. Cushing completed his general surgery residency at the Johns Hopkins Hospital in Baltimore under Dr. William Halsted. Afterwards, he pursued further training in neurology under Dr. Emil Theodor Kocher (for Dr. Kocher’s story, see Issue #2) and Dr. Charles Scott Sherrington. With his newly obtained expertise in neurology and his training in surgery, Cushing led the surgical cases of the central nervous system as the associate professor of surgery at Johns Hopkins Hospital. It was at his position in Johns Hopkins that Cushing was internationally recognized as the first specialist in neurosurgery, and thus the field of neurosurgery was born.

The recognition of Cushing was a direct result from his expertise of the pituitary gland and his careful procedures for safe removal of brain tumors. By 1931, Cushing had completed two thousand tumor excisions. In order for Cushing to establish the credibility of his specialty, he needed to prove the safety and efficacy of his methods. Cushing was one of the first to use diagnostic imaging, x-rays, to diagnose brain tumors and was able to improve survival of patients after tumor resection significantly. As a result, Cushing’s career was centered around his patients and their stories. Patients from far and wide were brought to him for his skill and accompanying compassion. During the development of his surgical legacy, he was also loved and respected by his patients and their families.

Cushing made many contributions to surgery, including developing surgical instruments commonly used even today. One of the most fundamental surgical instruments today is the Bovie electrocautery tool, commonly referred to as the “Bovie” for those of us who have scrubbed into the OR in our training. It was first developed by Dr. William T. Bovie, a physicist at Harvard, and first employed in neurosurgical cases with Dr. Cushing. Together with Bovie, Cushing was able to re-explore brain masses that were inoperable before because of the significant reduction in bleeding while operating with the Bovie electrocautery tool. Other surgical tools developed by Cushing include the Cushing forceps, used for grasping the tissues of the scalp during cranial surgeries, and the Cushing ventricular cannula, used for CSF drainage in the ventricles.

Even so, some of Cushing’s greatest contributions were towards the field of internal medicine, not just surgery. For example, Cushing was responsible for the inclusion of blood pressure as part of the vital signs during routine medical examination. After visiting his colleague Riva Rocci, an Italian internist and pathologist, Cushing improved the design of Rocci’s mercury sphygmomanometer for the use of non-invasive measurement of systolic blood pressure. Another notable medical discovery includes describing the condition bearing his name, Cushing’s disease, which he defined as an increase of ACTH secretion due to pituitary malfunction.

Dr. Cushing’s contributions greatly influenced modern surgery and medicine, and many of his practices have been adopted and standardized even to today. However, even outside of the well-deserved respect of his medical accomplishments, Dr. Cushing was a beloved doctor first and foremost, as recounted by many of his patients. He was also a memorable mentor to many influential names in medicine while in his academic post including Walter Dandy, Louise Eisenhardt, and Wilder Penfield.


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