Author: fidelmac

Timing of surgery following SARS‐CoV‐2 infection: an international prospective cohort study

Keeping surgery on hold for at least 7 weeks after a positive coronavirus test was associated with lower mortality risk compared with no delay, a large international study found.

Among 3,127 patients with a preoperative SARS-CoV-2 diagnosis, mortality was highest in those who had surgery the soonest after testing positive, Dmitri Nepogodiev, MBChB, of the University of Birmingham, England, and colleagues reported in Anaesthesia.

The 30-day postoperative mortality rates were:

• 9.1% for surgery within 2 weeks of diagnosis (104 of 1,138)
• 6.9% for surgery 3–4 weeks after testing positive (32 of 461)
• 5.5% for surgery 5–6 weeks after diagnosis (18 of 326)
• 2.0% for surgery 7 or more weeks post-diagnosis (24 of 1,202)

When compared with the adjusted 30-day mortality of 1.5% for surgery without SARS-CoV-2 infection, only the group with at least a 7-week interval between diagnosis and surgery didn’t have significantly elevated risk of death at 30 days.

https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15458

The Medial Sural Artery Perforator Flap in Lower Extremity Reconstruction

Abstract: Medial sural artery perforator (MSAP) flap is a thin, pliable, and versatile flap. It is a fasciocutaneous flap with chimeric design capacity. The donor site permits the synchronous harvesting of nonvascularized tendons and nerves. Free MSAP flap is suitable for foot, ankle, and distal one-third of the leg reconstructions. Pedicled MSAP flap is an alternative flap for knee and proximal two-thirds of leg defects, covering classical lower limb reconstruction territories of soleus, medial, and lateral gastrocnemius muscle flap. Computed tomography angiography, indocyanine green, and endoscopic-assist dissection enhances MSAP flap surgical planning and reduces its technical adversities and complications.

https://pubmed.ncbi.nlm.nih.gov/33674046/

While 2020 brought declines in surgical revenue and drops in patient intake, the COVID-19 pandemic caused a paradigm shift. Adaptations and innovations designed to cope with the pandemic could be a boon for the surgical field in 2021, and changes in malpractice coverage could impact how surgeons conduct business this year.

Some insights from the piece

• The comeback of elective surgery is on – surgical revenues are expected to jump and get back to pre-pandemic numbers, but surgeons should beware of burnout when trying to keep pace with surgical demands. Burnout is a leading cause of medical mistakes that can result in a malpractice claim.
• Medical malpractice insurance rates aren’t going down – but they aren’t going up either. Rates for neurosurgeons, orthopedic surgeons, plastic surgeons and bariatric surgeons maintained at their pre-pandemic prices.
• Make sure any surgical specialty is covered by insurance. With the rise in elective surgery, it is now more crucial than ever for bariatric surgeons and all surgical specialists to check their medical malpractice coverage and make sure they are protected.
• The future of robotic surgery in the wake of the pandemic. Robotic surgical tools like the da Vinci and Ion are providing new avenues for surgical teams to remotely perform surgery. Expect telemedicine too to play a larger role in the surgeon-patient relationship in 2021.

https://www.insurancejournal.com/news/national/2021/03/08/604060.htm

Published in J Laparoendosc Adv Surg Tech, the authors investigated 18 consecutive patients who underwent laparoscopic liver resection for superficial malignant tumors, namely 11 patients with hepatocellular carcinoma (HCC), 5 patients with colorectal liver metastases (CRLM), 1 patient with intrahepatic cholangiocarcinoma (ICC), and 1 patient with thyroid cancer metastasis, using Indocyanine  Green (ICG) fluorescence as an adjuvant tool to intraoperative laparoscopic ultrasound (LUS).

Results: An optimal ICG 15-minute clearance retention rate (R15 < 10%) and ICG plasma disappearance rate (<18%/minute) were present in 11 patients (61.1%) and in 14 patients (77.7%), respectively. Liver tumors were 29 in total, including 14 HCCs (48.3%), 13 CRLMs (44.8%), 1 ICC (3.4%), and 1 thyroid cancer metastasis (3.4%). Twenty-nine tumors (100%) were correctly visualized with ICG/fluorescence, as compared with 21 tumors identified with LUS (72.4%). After complete liver mobilization, ICG staining allowed to identify more superficial lesions (early HCC and small CRLM) in posterolateral segments (Segments 6 and 7) as compared with LUS (14 versus 10 lesions). In addition, in segments usually treated laparoscopically (e.g., left lateral segments), ICG was superior to LUS (10 versus 6 lesions) to identify superficial early HCC in patients with macronodular cirrhosis.

Conclusions: ICG visual feedback might substitute the tactile feedback of the hand and might in some cases act as a “booster” of LUS for superficial hepatic lesions.

https://pubmed.ncbi.nlm.nih.gov/33651631/

Background: As the coronavirus disease-2019 (COVID-19) pandemic continues globally, high numbers of new infections are developing nationwide, particularly in the U.S. Midwest and along both the Atlantic and Pacific coasts. Backlogged surgical cases now number in the tens of millions globally. Facilities will be hard-pressed to address these backlogs, even absent the recrudescence of COVID-19. This document provides guidance for the safe and effective resumption of surgical services as circumstances permit.

Methods: Review and synthesis of pertinent international peer-reviewed literature, with integration of expert opinion.

Conclusions: Resumption of surgical services requires institutional commitment (including teams of surgeons, anesthesiologists, nurses, pharmacists, therapists, dieticians, and administrators). Structured protocols and equitable implementation programs, and iterative audit, planning, and integration will improve outcomes, enhance safety, preserve resources, and reduce cost, all of which will contribute to safe and successful reduction of the surgical backlog.

Aesculap, Inc. announced its receipt of FDA 510(k) clearance for DIR800 3D digital infrared fluorescence for use with its Aesculap Aeos Robotic Digital Microscope.

The DIR800 is an accessory for the Aesculap Aeos Robotic Digital Microscope produces excitation light to illuminate the fluorescence properties of Indocyanine Green (ICG). DIR800 combines infrared fluorescence technology with 3D digital visualization while also allowing the surgeon and OR team to share the same high-quality live view and slow motion playback on multiple 3D 4K monitors. Backlight illumination aids visualization of nearby non-fluorescing structures without the need to switch back to white light.

https://finance.yahoo.com/news/aesculap-inc-receives-510-k-220700559.html

A study recently published in Surgery showed that the use of visual teaching aids is not well documented for common surgical procedures. The study showed that visual teaching aids improve recall of three major complications of a colectomy, improves understanding and reduces anxiety prior to a colectomy. They concluded that tools are needed that can reach patients with a wide range of health literacy.

https://www.americanjournalofsurgery.com/article/S0002-9610(21)00047-7/fulltext

A heartening picture showing number of confirmed cases dropping significantly since peak in January 2021

https://ourworldindata.org/coronavirus-data-explorer?zoomToSelection=true&time=2020-03-01..latest&country=USA~GBR~CAN~DEU~ITA~IND&region=World&casesMetric=true&interval=smoothed&perCapita=true&smoothing=7&pickerMetric=location&pickerSort=asc

Read the Paper

https://www.sciencedirect.com/science/article/abs/pii/S0039606020308436#:~:text=Although%20large%20comparative%20trials%20remain,cholecystectomy%20under%20white%20light%20alone

Recent developments in robotic surgery have led to an increasing number of robot-assisted hepatobiliary procedures. However, a limitation of robotic surgery is the missing haptic feedback. The fluorescent dye indocyanine green (ICG) may help in this context, which accumulates in hepatocellular cancers and around hepatic metastasis. ICG accumulation may be visualized by a near-infrared camera integrated into some robotic systems, helping to perform surgery more accurately. The study aimed to test the feasibility of preoperative ICG application and its intraoperative use in patients suffering from hepatocellular carcinoma and metastasis of colorectal cancer, but also of other origins.

“In a single-arm, single-center feasibility study, we tested preoperative ICG application and its intraoperative use in patients undergoing robot-assisted hepatic resections. Twenty patients were included in the final analysis. ICG staining helped in most cases by detecting a clear lesion or additional metastases or when performing an R0 resection. However, it has limitations if applied too late before surgery and in patients suffering from severe liver cirrhosis. ICG staining may serve as a beneficial intraoperative aid in patients undergoing robot-assisted hepatic surgery.

https://pubmed.ncbi.nlm.nih.gov/33503996/