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Issue #9: May 24th, 2023

On the Sea

It keeps eternal whisperings around

Desolate shores, and with its mighty swell

Gluts twice ten thousand Caverns, till the spell

Of Hecate leaves them their old shadowy sound.

Often ’tis in such gentle temper found,

That scarcely will the very smallest shell

Be moved for days from where it sometime fell.

When last the winds of Heaven were unbound.

Oh, ye! who have your eyeballs vexed and tired,

Feast them upon the wideness of the Sea;

Oh ye! whose ears are dinned with uproar rude,

Or fed too much with cloying melody—

Sit ye near some old Cavern’s Mouth and brood,

Until ye start, as if the sea nymphs quired!

–1817


HAPPENINGS THIS MONTH:

  • Congratulations to our new team of writers for the 2023-2024 school year. We thank everyone for applying and we are excited that this issue exhibits our new writers’ skills.

  • Want to hear more about another surgical subspecialty? Let us know!

  • Starting this July our Editorial board will be offering services to edit and advise on personal statements for Match 2024. If you are interested, email us.

  • This issue’s Surgeon of the Month is Sushruta



Have Surgical Site Infections (SSIs) finally met their match in D-PLEX100? Despite recent advancements, SSIs have, nonetheless, risen to become the number one cause of Healthcare Associated Infections (HAIs) in the United States, making up 42.4%. SSIs make up 19.5% of stated reasons for readmission after surgical procedures. The ideal solution to SSIs would be to contain it locally. D-PLEX100 is a potential solution that checks the box. It is a novel polymer–lipid based matrix that is paired with doxycycline that allows for local application to soft tissue wound surfaces and provides continual high potency exposure to doxycycline for 30 days.

This study was the post-hoc analysis of a prospective randomized phase 2 trial that compared rates of SSIs over 30 days postoperatively in patients who underwent elective colorectal surgery. Participants were randomly assigned to D-PLEX100 plus the Standard of Care (SOC) treatment (n=101) or solely SOC treatment (n = 100). The latter consisted of post-operative intravenous first or second generation cephalosporin and metronidazole. The results showed that at 30 days after surgery, the D-PLEX100 group (N=10/101 [9.9%]) had a 53% relative risk reduction (RRR) in comparison to the SOC group (N=21/100 [21%]; P=0.033). When comparing those who had more than 2 risk factors, SSI rates in those with the D-PLEX treatment were 15.8% whereas the SOC group was 37.5%, showing a RRR of 58% (p=0.042). The authors concluded that D-PLEX100 significantly reduced the incidence of SSI when compared to SOC prophylaxis, with further benefits in those who had 2 or more comorbidities. Because of the frequency of SSIs, novel formulations like D-PLEX100 have the potential to massively decrease the potential complications and readmissions following surgery. Additionally, the value of reducing costs for surgical patients can be tremendous. Though the paper provides a large sample size to compensate for the lack of power in previous studies, it refuses to address the downsides of D-PLEX100, choosing instead to argue on the lack of coverage in SOC prophylaxis vs D-PLEX100. Further studies in phase 3 or 4 would be highly beneficial to duplicate these results within a wider patient population.


Is Mr. Roboto better for post-surgical outcomes? When given the choice between robotic and laparoscopic procedures, how do we determine what is best for the patient? A previous PROVE-IT study in 2021 showed no significant differences in pain, hospital length of stay, and discharge time between the patients conducting robotic vs laparoscopic ventral hernia repair. In this randomized clinical trial conducted, researchers took a step further to explore the one-year post-surgical outcomes of robotic versus laparoscopic ventral hernia repair with intraperitoneal mesh.The outcomes evaluated included pain intensity (PROMIS 3a), quality of life specific to having a hernia (HerQLes), recurrence of hernia (HRI), and any reoperations performed. The study determined that there was no difference in pain intensity or rate of reoperation between the two groups (p=0.94 and p=0.61 respectively). However, there was significant improvement in the HerQLes score in the robotic group, indicating improved quality of life, compared to the laparoscopic group (p=0.03). Additionally, 24% of robotic surgeries had a composite hernia recurrence, compared to 6% in the laparoscopic group. Given the data, the study suggests that there is evidence that robotic hernia repairs are superior. And yet, the laparoscopic repairs showed a lower incidence of hernia recurrence. Therefore, there is no clear answer to which approach is better. Further investigation can involve following patients at risk of poor out-comes or with comorbid conditions compared to healthier individuals with no previous surgical history. Do certain patient groups benefit more from robotic surgeries versus other groups?


Could management of your diet improve your post-surgical outcomes following Colorectal Cancer Surgery? Currently, the literature on the effect of dietary fiber intake on post-operative complications, like anastomotic leakage, infections, or ileus, is minimal. Fiber has long been known to be beneficial to gut health by improving digestion and optimizing transit time. In this cohort study, researchers dived in to determine whether habitual fiber intake could improve postoperative complications in patients undergoing colorectal cancer surgery. Participants were asked to self-report their total fiber intake using a 204-item food frequency questionnaire (FFQ) which specified sources of fiber intake. Using logistic regression analysis, the outcomes were analyzed 30 days after surgery. The study found that higher fiber intake was associated with a lower occurrence of surgical complications (OR, 0.76; 95% CI, 0.6-0.97). Interestingly, there was a lower risk of post-operative complications in women (OR, 0.64; 95% CI, 0.44-0.49), and no significant risk reduction was seen in men. The study also decided to compare patients undergoing surgery for colon cancer vs rectal cancer. While no significant risk reduction was seen with increased dietary fiber intake in patients undergoing colon cancer procedures, there was a statistically significant decrease in risk in patients with rectal cancer procedures (OR, 0.71; 95% CI, 0.51-0.98). Finally, a pre-operative fiber intake consisting of mostly vegetables was shown to have the greatest association with a decreased risk in post-operative complications (OR, 0.9; 95% CI, (0.83-0.99). Prehabilitation programs have an opportunity to incorporate dietary fiber intake into routine preparation for those undergoing colorectal surgery in the future. Advances in patient care in the weeks leading up to a surgical procedure can improve the overall quality of life and satisfaction of the patient and the effectiveness of the procedure itself.


G.I. Joe: the rise of Artificial Intelligence (AI). AI has overtaken the world and broadened scientific and research horizons. Good technical surgical skills are essential, and are often subjectively assessed by professionals, such as GEARS (The global Evaluative assessment of Robotic Skills) in robotic surgery. In specific application to peritoneal closure during robotic rectopexy, this article attempts to standardize and render objective assessment techniques in surgery. It is an attempt to generate quantitative feedback for the trainees, uninfluenced by variable subjective experts’ reviews. PGY3- PGY7 level trainees with variable robotic experience assisted colorectal surgeons using standardized instruments and were recorded on Stryker systems. Deep learning models were established, trained and validated using the 54 de-identified videos. The trained AI model and six board-certified general surgeons assessed the surgical skills on five continuous suture throws during peritoneal closure using the GEARS tool. Amongst surgeons, the highest correlation was observed for the assessment of efficiency and bimanual dexterity domains of GEAR that were further compared with the AI model. The distance traveled by each tool determined the efficiency with more skilled surgeons having a lower tool distance 81.9 vs 156.93 for less proficient ones; p <0.001). For dexterity, proficient surgeons had greater time with simultaneous bimanual movements (62.96% vs 52%; p <0.001) compared to lower-skilled surgeons. The AI and surgeons’ correlation was -0.72 and 0.48 for both domains respectively. The implication of this high correlation using AI, which is difficult to reproduce among human experts, is to automate a portion of skills assessment and provide reproducible feedback. I believe with further refinement and training on other metrics, a larger cohort to train deep learning models on, and an increased emphasis on competency-based learning in residency, AI will soon be able to establish a standardized assessment platform. The question is not only when but also how it will play out to be integrated into training programs especially the impact on certification exams assessing robotic (FRS) or laparoscopic skills (FLS).



Subspecialties: Cardiothoracics/Vascular


Rheumatic heart disease (RHD) is a well-known cause of mitral valve malfunction and has historically been treated with either mitral valve repair (MVP) or mitral valve replacement (MVR), although MVP has been preferred. However, the superiority of MVP in treating RHD patients is still debatable. The pathogenic characteristics of the rheumatic mitral valve make repair of these valves technically both more complicated and complex. In this meta-analysis, the clinical outcomes of MVP and MVR RHD patients were analyzed in 16 clinical trials to fully ascertain if MVP for these patients.

Early and late mortality, and the ratio of valve-related events were all reduced in the MVP group versus the combined data for mechanical and bioprosthetic valve replacements. More patients required reoperation in the MVR cohorts overall. Interestingly, patients in the MVP group had a greater risk of needing reoperations (mech-valves), but there was no statistically significant difference in the rate of reoperation between MVP and MVR (bio-valves). Amongst patients with RHD, both MVP and MVR are useful options when addressing mitral valve disease, and yet, skilled surgeons still preferred MVP. But MVR may be a better choice over MVP if aortic valves need to be replaced concomitantly.

The study had a variety of limitations including: the lack of randomized controlled studies, the limited selection of studies, the wide range of operative years reported and the variations in mitral repair methods and techniques. The latter may be partly attributable to the surgeons' varying levels of experience and thus success. Atrial fibrillation and age are not predictors of increased survival, according to this research, but further research is needed to understand the functions of these predictive elements. Surprisingly, two conditions—years of expertise in executing this repair and knowledge of the anatomy of the valve— must be satisfied in order to achieve effective repair rather than other patient-related aspects.


Subspecialties: Orthopedics


Proximal humeral fractures are common among the elderly, and lead to significant disability and financial burdens. There is significant debate about whether these fractures should be addressed conservatively or surgically. Though the literature continues this debate, it specifically is limited on what is the most superior operation, if surgery is decided. In this randomized single blinded prospective clinical trial, researchers aimed to compare post-operative outcomes for a reverse total shoulder arthroplasty (RSTA) versus open reduction internal fixation (ORIF) with an angular stable plate.

The 2007 OTA/AO classification was used to enroll only those with type B2 or C2 displacements. Type B2 is defined as extra-articular bifocal fracture without metaphyseal impaction. Type C2 fracture is defined as articular fractures with marked displacement. Severely displaced fractures were defined as > 45° valgus or > 30° varus displacement in the A/P projection, > 45° angulation in the scapular Y projection, or > 50° displacement of the humeral head relative to the metaphysis.64 patients were allocated to the RSTA treatment group with either the Delta Xtend Reverse Total Shoulder Arthroplasty (52 patients) or Promos Reverse Prosthesis (12 patients) and 60 patients were allocated to ORIF with the PHILOS angular stable plate treatment group. Primary outcomes were measured with the Constant Score, which ranges from 0 (no shoulder function) to 100 (excellent) and were calculated at various measures, including: Pain (15 points), Activities of Daily Living (20), Range of Motion (40), and Strength (25).

At two years, the RTSA group constant score mean was 68.0 (95% CI, 63.7 to 72.4 points) and the ORIF group mean score was 54.6 points (95% CI, 48.5 to 60.7 points). The RTSA group scored significantly better with a mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p <0.001). When stratified by fracture classification, RTSA repair of C2 fractures showed a mean difference improvement of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). This study provides strong evidence that if surgical treatment is elected, a RTSA should be performed for proximal displaced humeral fractures in the elderly, especially type C2. And yet, the limitation laid bare is the possibility in difference in surgical technique, depending on the surgeon. Further analysis should confront this limitation to get a complete picture on what procedure is most superior.


Restoration of ankle function and mobility following ankle fracture presents unique challenges due to complexity of the ankle anatomy. The distal tibiofibular syndesmosis (DTS) is a fibrous joint essential to the maintenance of ankle mobility and overall functionality. The traditional fixation technique used for DTS stabilization was cortical screw fixation. However, the technique presents complications due to requiring a second operation for screw removal before weight bearing, potential screw fracture, and increased risk of infection. New techniques involving elastic fixation are proving to yield more favorable outcomes in DTS stabilization, specifically the nice knot, a double-line sliding knot.

In this retrospective study, patients with ankle fractures and subsequent DTS injury were divided into two groups based on treatment method (cortical screw fixation or elastic fixation with nice knot encircling). Patients were observed post-operatively based on operation time, time to partial and full weight bearing, visual analog scale (VAS) for pain, and American Foot Surgery Association Ankle-Hindfoot Score (AOFAS) for pain and function.

The results demonstrated that the elastic binding group (n=33) had shorter operative times, time to partial weight bearing and time to full weight bearing compared to the cortical screw group (n=34) (p≤0.023). Additionally, the VAS was lower and the AOFAS higher for the EB group compared to the CS group. Thus, the study supports the findings that elastic fixation techniques, such as the nice knot, provide better patient outcomes related to regaining functionality faster, reducing potential risk factors, and reducing financial burden on patients. Although the study provides future promise for elastic fixation techniques, it has limitations due to the small sample size, which confines the generalizability to diverse patient populations.


Subspecialties: Neurosurgery


Large ischemic strokes have largely been excluded from trials investigating therapeutic options for stroke given their overall poor functional outcome. There are two main options for treating ischemic stroke: medical therapy (thrombolysis, blood pressure management, supportive care) and/or thrombectomy. The original trials evaluating the treatment options for stroke excluded patients with “large core” strokes, defined as less than 6 on the Alberta Stroke Program Early CT Score (ASPECT). This score is used to quantify the number of predetermined brain regions involved using brain imaging, from 0-10 with a lower number indicating more regions. Due to these restrictions, there is not a well-established standard of care for large core ischemic stroke.

In this randomized controlled trial, patients experiencing a large core ischemic stroke were divided into two treatment groups to determine the most effective therapeutic option based on functional outcome. The first group (n=178) underwent endovascular thrombectomy plus medical therapy while the second group (n=174) only received medical therapy. Outcomes were quantified using the modified Rankin scale (mRs) (0-6, with a larger number indicating more severe disability) and quality of life measures at 90 days after stroke onset (T scores, higher values indicate better performance).

The thrombectomy group experienced significantly less disability than the medical therapy group (median mRs 4 vs. 5, OR 1.51, 95%CI 1.20-1.89). The thrombectomy group had greater functional independence (20% vs 7%, RR 2.97, 95% CI 1.60-5.51), mobility (35.2 vs 25.1, effect size 10.10, 95% CI 5.02-15.18) and social interaction (37.1 vs 33.5, effect size 3.6, 95% CI 1.11-6.09). The thrombectomy cohort also had less depression than medical therapy alone (47.9 vs 53.6, effect size -5.70, 95% CI -8.83 - 2.57). However, the thrombectomy procedure was not without risks as it led to five arterial access site complications, and thirty vascular injury complications. Overall, mortality was not significantly different between the groups. This study shows thrombectomy in the treatment of large core ischemic strokes leads to an immense positive effect, providing crucial data to direct treatment decisions.


With the more indolent natural course of diffuse low-grade gliomas (dLGG), there has been a lack of consensus on how to approach initial management. Some have believed that a more conservative approach, involving a biopsy followed by wait-and-scan, will give the patient a better quality of life. This reserves aggressive surgery when the tumor is symptomatic from mass effect. Others state that regardless of mass effect, the tumor should be taken out as early as possible. In this retrospective population-based parallel cohort study, researchers attempted to compare the 10 year outcomes at 2 different centers, each promoting differing policies on whether to turn to surgery. In other words, the study is trying to create a consensus focusing specifically on the effects of the differing initial treatment approaches and how it impacts long-term survival.

Two regions within Norway were chosen, each with a different approach to the management of dLGG. Region A (n=31) favored a more conservative approach, including a biopsy and wait-and-scan, while Region B (n=53) underwent early 3D ultrasound guided resection as the preferred, more aggressive strategy. Patient’s records included at least 10 years of follow-up and statistical analysis primarily compared overall survival in each region between cohorts. Additionally, fifty-nine of the eighty-four patients completed the EG-5D-3L questionnaires which were used at a median of 6.9 years after surgery to assess health-related quality of life (HRQOL).

Overall survival was significantly worse in region A, which favored a biopsy and wait-and-scan approach, compared with region B which preferred early resection (p=0.04). In all three HRQOL measures, there were no significant differences when scores were compared against the cohorts. With survival rates being significantly higher in earlier and more aggressive treatment, there is a considerable advantage to surgical resection over a more conservative, wait-and-scan approach. This advantage not only leads to improved survival, but also comes with no compromise to the patients long term HRQOL. Given these results, management of dLGGs should include early resection whenever possible.


Subspecialties: OB/GYN


The debate for the standard of care in surgical treatment of intestinal deep infiltrating endometriosis (DIE) is ongoing. DIE is a subdivision of endometriosis that is associated with the highest risk of sexual dysfunction. Common symptoms include dyspareunia, chronic pelvic pain, decreased lubrication, and hypoactive sexual desire disorder. It causes a profound reduction in overall quality of life psychosocially, physically, and sexually. Endometriosis is also associated with a 9-fold increase in risk of dyspareunia compared with the general population. However, few studies have investigated the long-term effects on Sexual Quality of Life (SQL) and Health-Related Quality of Life (HRQL) after surgical resection.

In this prospective long-term case-control study, researchers divided patients into two groups; one group consisting of pre-menopausal women with DIE who underwent laparoscopic excision, and the other consisting of 64 healthy women who underwent tubal ligation. The purpose was to quantitatively compare the SQL and HRQL in sexually active patients undergoing laparoscopic surgery for DIE. Three separate questionnaires were utilized to evaluate SQL and HRQL in patients followed for a minimum follow-up of 36 months post-surgery. SQL and HRQL significantly improved in patients with DIE who underwent complete laparoscopic resection as demonstrated by their questionnaire responses at 6 months post-op (p <0.001), with a partial decline in this improvement at 36 months (p<0.001). In general, female sexual functioning is not a forethought, and often placed in the corner of backgrounds, when it comes to importance in society and identifying effective treatment for underlying disease.

Endometriosis is a global disease, affecting not only sexual health but overall quality of life in patients affected. While this study has its limitations, specifically the small number of patients in the healthy control group and the fact that data came from a single hospital, the conclusions cannot be denied. As such, this study is an important step forward in patient-centered surgical care.



Subspecialties: Urology


Will new technology take over for future nephrectomies? Nephrectomy techniques continue to improve with modern advances, but they can only replace conventional techniques if the benefits outweigh the risks. This retrospective study reflects just such a scenario with respect to the surgical management of patients with benign inflammatory non –functioning kidney disease. Various pre-operative, intraoperative and post-operative factors play a vital role in determining outcome of a surgical procedure along with the surgical skills of a surgeon.

With a sample size of 223, 142 patients underwent Modified Hand Assisted Retroperitoneoscopic Laparoscopic Nephrectomy (MHARLN) and 81 underwent open nephrectomies (ON). Preoperatively, there was no significant variation in data between MHARLN and ON cohorts. Intra-operatively, the operative time was 134 min and 142 min respectively for MHARLN and ON with p value of 0.181. The estimated blood loss was more than two times that of MHARLN cases for ON as compared to MHARLN ( 139.6 ml in MHARLN and 309.8 ml in ON, with p value of 0.036). Fever in the first postoperative day occurred more often for patients that underwent ON as compared to MHARLN. Post-operatively MHARLN lower Visual Analog Pain Scale Score (VAS Scores) (p value 0.058), shorter time to liquid diet (p value of 0.004) and shorter hospital stays (p value of 0.048).

When performed by surgeons with sufficient experience the outcome of modern advanced technique are superior. On the other hand, in remote setups and developing countries, conventional techniques are still considered the gold standard due to low cost and easy availability of services. Some limitations of this study include the fact that The study was single centered and that The long term outcomes and follow up were not reported.In a nutshell, the subtle skills of an adept surgeon plays a pivotal role in paving the way for Modern Advanced Surgery in the field of Urology.


Radiology


From Hydration to Diagnosis: The Curious Connection Between Water Bottles and Pericardial Effusion

On a frontal chest x-ray, a pericardial effusion can be identified as the "water bottle sign". In the frontal view (Figure A), observations reveal an enlarged cardiac silhouette, characterized by an increased transverse diameter. Additionally, the right ventricle appears to be comparable in size to the left ventricle, which is an abnormal finding. The accumulation of excess fluid within the pericardial sac causes it to sag downward, creating a distinctive resemblance to a water bottle sagging on a bench. Similarly, the lateral view (Figure B) also demonstrates a spherical enlargement of the cardiac silhouette, consistent with the aforementioned findings. The recommended interventions to address this condition are pericardiocentesis or pericardiotomy.


Source(s):


SURGEON SPOTLIGHT OF THE MONTH

Sushruta


In this issue, we will examine the legacy of Sushruta, the father of Indian surgery from the Vedic period. Although Sushruta’s surgical teaching took place in 600 BC, many of his surgical texts still have lasting relevance in modern medicine. A pioneer of the ancient practice of surgery, Sushruta was also one of the first advocates for medical education by suggesting practicing with autopsies to familiarize oneself with the human body. Sushruta thought of surgery in its most noble sense- a complete subject that was not separate from traditional medicine, but rather an all-encompassing art and science that required thorough understanding and dedication to fully develop an acumen.

Sushruta’s contributions to surgery were outlined in the “Sushruta Samhita,” (Sushrita’s compendium) which were the annals of the basis of medicine, surgery, ethics, and theory at that time. This era of civilization was within the Vedic period (5000 BC), where the Vedas, or the foundation of Indian teaching, was transcribed in the Sanskrit language for all to learn from and follow if they so choose. Sushruta created a series of Vedas, including the Rigveda, Samaveda, Yajurveda, and Atharvaveda. In the series, he detailed disciplines spanning from complex facial plastic surgery, flap dissections, obstetrics, and even the ramifications of mental illness. Sushruta further detailed uses of intoxicants such as wine and henbane as anesthetic agents for surgery, revolutionary in his time. As a testament of Sushruta’s legacy in the surgical arts, rhinoplasty described in his texts are referred to as the “Indian flap” in contemporary plastic surgery. Amidst these discussions, he also outlined how to conduct a proper surgery, with the importance of maintenance of hygiene of the surgeon and surgical space, minimizing pain, maximizing positive outcomes, communication with the patient, and preparation through constant study.

Sushruta epitomized the basis of medicine by creating a strong framework for generations of healthcare workers to understand and live by. Eventually the loss of the original text prompted efforts by Buddhist scholar Vasabandhu (AD 360-350) to rewrite it, which allowed Sushruta’s traditions to transcend to different nations and languages, such as Arabic, English, German, and Latin. Well ahead of his time, Sushruta’s collective teaching can be regarded as a code of ethics that is very much respected even in our modern practices of medicine and surgery.



Sources:

  • Bhattacharya, Surajit. "Sushruta—the Very First Anatomist of the World." Indian Journal of Surgery 84, no. 5 (2022): 901-904. https://rdcu.be/dcCwu

  • Saraf, Sanjay, and Ravi S. Parihar. "Sushruta: the first plastic surgeon in 600 BC." Int J Plast Surg 4, no. 2 (2007). https://ispub.com/IJPS/4/2/8232

  • Singh, Vibha. "Sushruta: The father of surgery." National journal of maxillofacial surgery 8, no. 1 (2017): 1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5512402/



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