Intraoperative adverse events among surgeons in Singapore: a multicentre cross-sectional study on impact and support.

BACKGROUND: It is known that many surgeons encounter intraoperative adverse events which can result in Second Victim Syndrome (SVS), with significant detriment to their emotional and physical health. There is, however, a paucity of Asian studies in this space. The present study thus aimed to explore the degree to which the experience of an adverse event is common among surgeons in Singapore, as well as its impact, and factors affecting their responses and perceived support systems. METHODS: A self-administered survey was sent to surgeons at four large tertiary hospitals. The 42-item questionnaire used a systematic closed and open approach, to assess: Personal experience with intraoperative adverse events, emotional, psychological and physical impact of these events and perceived support systems. RESULTS: The response rate was 57.5% (n = 196). Most respondents were male (54.8%), between 35 and 44 years old, and holding the senior consultant position. In the past 12 months alone, 68.9% recalled an adverse event. The emotional impact was significant, including sadness (63.1%), guilt (53.1%) and anxiety (45.4%). Speaking to colleagues was the most helpful support source (66.7%) and almost all surgeons did not receive counselling (93.3%), with the majority deeming it unnecessary (72.2%). Notably, 68.1% of the surgeons had positive takeaways, gaining new insight and improving vigilance towards errors. Both gender and surgeon experience did not affect the likelihood of errors and emotional impact, but more experienced surgeons were less likely to have positive takeaways (p = 0.035). Individuals may become advocates for patient safety, while simultaneously championing the cause of psychological support for others. CONCLUSIONS: Intraoperative adverse events are prevalent and its emotional impact is significant, regardless of the surgeon's experience or gender. While colleagues and peer discussions are a pillar of support, healthcare institutions should do more to address the impact and ensuing consequences.

Scoping review of the second victim syndrome among surgeons: Understanding the impact, responses, and support systems.

BACKGROUND: It is thought that 50% of healthcare providers experience Second Victim Syndrome (SVS) in the course of their practice. The manifestations of SVS varies between individuals, with potential long-lasting emotional effects that impact both the personal lives and professional clinical practice of affected persons. Although surgeons are known to face challenging and high-stress situations in their profession, which can increase their vulnerability to SVS, majority of studies and reviews have focused squarely on nonsurgical physicians. METHODS: This scoping review aimed to consolidate existing studies pertaining to a surgeon's experience with SVS, by broadly examining the prevalence and impact, identifying the types of responses, and evaluating factors that could influence these responses. The scoping review protocol was guided by the framework outlined by Arksey and O'Malley and ensuing recommendations made by Levac and colleagues. Three databases (MEDLINE, EMBASE and Cochrane Library) were searched from inception till March 19, 2023. RESULTS: A total of 13 articles were eligible for thematic analysis based on pre-defined inclusion criteria. Effects of SVS were categorized into Psychological, Physical and Professional impacts, of which Psychological and Professional impacts were particularly significant. Factors affecting the response were categorized into complication type, surgeon factors and support systems. CONCLUSION: SVS adds immense psychological, emotional and physical burden to the individual surgeon. There are key personal, interpersonal and environmental factors that can mitigate or exacerbate the effects of SVS, and greater emphasis needs to be placed on improving availability and access to services to help surgeons at risk of SVS.

Local Therapy on Clinically Lymph Node-positive Prostate Cancer: A Systematic Review and Meta-analysis.

CONTEXT: Patients with clinically lymph node-positive (cN1) prostate cancer (PCa) are traditionally regarded to have metastatic disease, and the role of local therapy (LT) in their treatment remains unclear. OBJECTIVE: To evaluate the outcomes of cN1 PCa patients treated with LT, and secondarily to compare between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). EVIDENCE ACQUISITION: A bibliographic search was performed using Medline, Embase, and the Cochrane Library to identify studies comparing the survival outcomes of cN1 PCa patients treated with LT (RT or RP) with those who did not receive any form of LT (observation or androgen deprivation therapy alone). The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) recommendations were followed. Survival outcomes of the addition of LT were assessed using a random-effect model. EVIDENCE SYNTHESIS: A total of 8522 patients across eight studies were included. LT significantly improved overall survival (OS) across all time points from 2 to 10 yr compared with patients without LT, most notably providing a durable benefit in 10-yr OS (odds ratio [OR]: 1.49, 95% confidence interval [CI] 1.06-2.10). Both RT and RP were associated with benefits to both OS and recurrence-free survival, with no significant difference in OS between both modalities in medium-term follow-up (4-yr OR: 0.76, 95% CI 0.41-1.40, p = 0.19). CONCLUSIONS: Regardless of modality, the use of LT in cN1 patients improved OS. Future studies should aim to identify patients who could benefit from LT and include more comprehensive survival data including biochemical recurrence. PATIENT SUMMARY: In this study, we evaluated the outcomes of clinically lymph node-positive (cN1) prostate cancer (PCa) patients treated with local therapy (LT) and compared between different modalities of LT, including radiotherapy (RT) and radical prostatectomy (RP). We found that the addition of LT for cN1 PCa patients leads to a significant improvement in survival outcomes, most notably for overall survival, with no significant difference between RT and RP.

Should Procalcitonin Be Included in Acute Cholecystitis Guidelines? A Systematic Review.

Background and Objectives: Acute cholecystitis (AC) is a common surgical emergency. Recent evidence suggests that serum procalcitonin (PCT) is superior to leukocytosis and serum C-reactive protein in the diagnosis and severity stratification of acute infections. This review evaluates the role of PCT in AC diagnosis, severity stratification, and management. Materials and Methods: PubMed, Embase, and Scopus were searched from inception till 21 August 2022 for studies reporting the role of PCT in AC. A qualitative analysis of the existing literature was conducted. Results: Five articles, including 688 patients, were included. PCT ≤ 0.52 ng/mL had fair discriminative ability (Area under the curve (AUC) 0.721, p < 0.001) to differentiate Grade 1 from Grade 2-3 AC, and PCT > 0.8 ng/mL had good discriminatory ability to differentiate Grade 3 from 1-2 AC (AUC 0.813, p < 0.001). PCT cut-off ≥ 1.50 ng/mL predicted difficult laparoscopic cholecystectomy (sensitivity 91.3%, specificity 76.8%). The incidence of open conversion was higher with PCT ≥ 1 ng/mL (32.4% vs. 14.6%, p = 0.013). A PCT value of >0.09 ng/mL could predict major complications (defined as open conversion, mechanical ventilation, and death). Conclusions: Current evidence is plagued by the heterogeneity of small sample studies. Though PCT has some role in assessing severity and predicting difficult cholecystectomy, and postoperative complications in AC patients, more evidence is necessary to validate its use.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis.

BACKGROUND: For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery. METHODS: Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity. RESULTS: Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively. CONCLUSIONS: As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

A Systematic Review and Meta-Analysis of the Clinical Use of Megestrol Acetate for Cancer-Related Anorexia/Cachexia.

Cancer-related anorexia/cachexia is known to be associated with worsened quality of life and survival; however, limited treatment options exist. Although megestrol acetate (MA) is often used off-label to stimulate appetite and improve anorexia/cachexia in patients with advanced cancers, the benefits are controversial. The present meta-analysis aimed to better elucidate the clinical benefits of MA in patients with cancer-related anorexia/cachexia. A systematic search of PubMed, EMBASE, OVID Medline, Clinicaltrials.gov, and Google Scholar databases found 23 clinical trials examining the use of MA in cancer-related anorexia. The available randomized, controlled trials were appraised using Version 2 of the Cochrane risk-of-bias tool (RoB 2) and they had moderate-to-high risk of bias. A total of eight studies provided sufficient data on weight change for meta-analysis. The studies were divided into high-dose treatment (>320 mg/day) and low-dose treatment (≤320 mg/day). The overall pooled mean change in weight among cancer patients treated with MA, regardless of dosage was 0.75 kg (95% CI = −1.64 to 3.15, τ2 = 9.35, I2 = 96%). Patients who received high-dose MA tended to have weight loss rather than weight gain. There were insufficient studies to perform a meta-analysis for the change in tricep skinfold, midarm circumference, or quality of life measures. MA was generally well-tolerated, except for a clear thromboembolic risk, especially with higher doses. On balance, MA did not appear to be effective in providing the symptomatic improvement of anorexia/cachexia in patients with advanced cancer.

A Systematic Review of the Clinical Use of Gabapentin and Pregabalin in Bipolar Disorder.

Despite its prevalence and disease burden, several chasms still exist with regard to the pharmacotherapy of bipolar disorder (BD). Polypharmacy is commonly encountered as a significant proportion of patients remain symptomatic, and the management of the depressive phase of the illness is a particular challenge. Gabapentin and pregabalin have often been prescribed off-label in spite of a paucity of evidence and clinical practice guidelines to support its use. This systematic review aimed to synthesize the available human clinical trials and inform evidence-based pharmacological approaches to BD management. A total of six randomized, controlled trials (RCTs) and 13 open-label trials involving the use of gabapentin and pregabalin in BD patients were reviewed. Overall, the studies show that gabapentin and its related drug pregabalin do not have significant clinical efficacy as either monotherapy or adjunctive therapy for BD. Gabapentin and pregabalin are probably ineffective for acute mania based on the findings of RCT, with only small open-label trials to support its potential adjunctive role. However, its effects on the long-term outcomes of BD remain to be elucidated. The evidence base was significantly limited by the generally small sample sizes and the trials also had heterogeneous designs and generally high risk of bias.

Different position from traditional left lateral for colonoscopy? A meta-analysis and systematic review of randomized control trials.

BACKGROUND: Colonoscopy requires the intubation of the cecum for screening of colorectal diseases. The conventional position used for colonoscopy is the left lateral position (LLP). However, alternative positions have also been utilized to enhance the success of intubation. Thus, the aim of this study was to perform a meta-analysis of the different positions to determine the effectiveness of the individual positions for successful colonoscopy. METHODS: Medline, Embase and Cochrane trials electronic databases were searched for studies on colonoscopy positions. The primary outcome was defined as the cecal intubation rate. Pooled risk ratios (RR) and 95% confidence intervals (CI) for the rates of cecal intubation were estimated. Secondary outcomes such as the cecal intubation time and adenoma detection rate were further analyzed qualitatively. RESULTS: After reviewing 644 identified records, 7 randomized control trials (RCT) studies were included. No significant difference was observed in either comparisons, between the LLP vs. supine position (SP) (RR = 1.01, 95% CI, 0.98 to 1.04, P = 0.55) or the LLP vs. prone position (PP) (RR = 1.02, 95% CI, 0.98 to 1.06, P = 0.27). CONCLUSIONS: Amidst available literature, the use of other positions can be considered when performing colonoscopy. These further highlights that the existential practice is based predominantly on familiarity instead of evidence-based-research.

Early surgery after bridge-to-surgery stenting for malignant bowel obstruction is associated with better oncological outcomes.

BACKGROUND: Placement of self-expanding metal stents has been increasingly adopted as a bridge to surgery in patients presenting with obstructed left-sided colorectal cancers. The optimal bridging time has yet to be widely established, hence this retrospective study aims to determine the optimal bridging time to elective surgery post endoluminal stenting. PATIENTS AND METHODS: All patients who underwent colorectal stenting for large bowel obstruction in a single, tertiary hospital in Singapore between January 2003 and December 2017 were retrospectively identified. Patients' baseline demographics, tumour characteristics, stent-related complications, intra-operative details, post-operative complications and oncological outcomes were analysed. RESULTS: Of the 53 patients who successfully underwent colonic stenting for malignant left sided obstruction, 33.96% of patients underwent surgery within two weeks of stent placement while 66.04% of patients underwent surgery after 2 weeks of stent placement. Univariate analysis between both groups did not demonstrate significant differences in postoperative complications and stoma formation. Significant differences were observed between both groups for stent complications (38.89% vs 8.57%, p = 0.022), on-table decompression (38.89% vs 2.86%, p = 0.001) and systemic recurrence (11.11% vs 40.00%, p = 0.030). Increased bridging interval to surgery (OR 13.16, CI 1.37-126.96, p = 0.026) was a significant risk factor for systemic recurrence on multivariate analysis. CONCLUSIONS: Patients undergoing definitive surgery within 2 weeks of colonic stenting may have better oncological outcomes without compromising on postoperative outcomes. Further prospective studies are required to compare outcomes between emergency surgery and different bridging intervals.

Indocyanine green fluorescent imaging on anastomotic leakage in colectomies: a network meta-analysis and systematic review.

PURPOSE: The usage of indocyanine green (ICG) dye is commonly associated with decreased anastomotic leakage rates in colectomies. This study aims to perform a network meta-analysis to assess the usage of ICG fluorescence imaging in right-sided colectomies. METHODS: Medline, Embase, Cochrane Trials, CNKI, and WanFang electronic databases were reviewed, and meta-analysis of proportions, comparative meta-analysis, and network meta-analysis were conducted in this review. Studies comparing ICG usage with conventional approaches of anastomosis were selected, with postoperative anastomotic leak rate being the primary outcome. RESULTS: Ten articles were included, with a total of 675 patients involved, of which 515 patients underwent colorectal surgery with ICG. Anastomotic leak rates with ICG were estimated to be 1% (CI 0.00-0.04) and 3% (CI 0.01-0.06) for right and left procedures, respectively. No significant difference was observed in left-sided colectomies (OR 0.587; 95% CI 0.218-1.582; p = 0.292). There were nearly half the odds of anastomotic leakage when ICG was used in right-sided colectomies (OR 0.524; 95% CI 0.128-2.137). CONCLUSION: With the ability to potentially avert postoperative anastomotic leakage, coupled with its minimal costs and side effects, administration of ICG in colectomies in centers where equipment is available should be encouraged.

Difficulties Faced by General Surgery Residents. A Qualitative Systematic Review.

BACKGROUND: General surgery residency training is academically rigorous, taxing and involves complex operative procedures. These trainings are synonymous with alarming burnout rates, high incidence of mistreatment reports and lower job satisfaction. Moreover, the established association between residents' levels of well-being and their capacity for empathy and patient care, emphasises the urgency to mitigate the negative connotations relating to surgical training. This systematic review aims to circumnavigate the multitude of problems faced by general surgical residents in training. STUDY DESIGN: Literature searches were conducted on electronic databases Medline, PsycINFO, Embase, CINAHL, and Web of Science Core Collection using specific search criteria. Studies that analyzed the difficulties faced by General Surgery residents were eligible for inclusion Qualitative analysis involved the derivation of analytical themes and grouping data extracted from the papers accordingly. RESULTS: After review of the full study texts, 19 studies met the inclusion criteria. The 3 main analytical themes identified were Problems regarding the Residency Programme, Work Associated Challenges, and Personal Concerns. Problems Regarding Residency Training was associated with residents' lack of experience. Work Associated Challenges highlighted problems with peer interactions, autocratic relationships, and communication with patients. Personal Concerns includes work-life balance, personal well-being and gender biases. CONCLUSION: This systematic review delves into several prevalent difficulties that general surgical residents face, ranging from work related issues to personal difficulties. The results of this review can be used to provide complementary supportive measures for general surgical residents.