The impact of the COVID-19 pandemic on elective laparoscopic cholecystectomy: A retrospective Cohort study.

The coronavirus disease 2019 (COVID-19) pandemic had a significant impact on elective surgery for benign disease. We examined the effects of COVID-19 related delays on the outcomes of patients undergoing elective laparoscopic cholecystectomy (LC) in an upper gastrointestinal surgery unit in the UK. We have analysed data retrospectively of patients undergoing elective LC between 01/03/2019 to 01/05/2019 and 01/04/2021 to 11/06/2021. Demographics, waiting time to surgery, intra-operative details and outcome data were compared between the two cohorts. Indications for surgery were grouped as inflammatory (acute cholecystitis, gallstone pancreatitis, CBD stone with cholangitis) or non-inflammatory (biliary colic, gallbladder polyps, CBD stone without cholangitis). A p value of <0.05 was used for statistical significance. Out of the 159 patients included, 106 were operated pre-pandemic and 53 during the pandemic recovery phase. Both groups had similar age, gender, ASA-grades and BMI. In the pre-pandemic group, 68 (64.2%) were operated for a non-inflammatory pathology compared to 19 (35.8%) from the recovery phase cohort (p < 0.001). The waiting time to surgery was significantly higher amongst patients operated during the recovery phase (p = 0000.1). Less patients had complete cholecystectomy during the pandemic recovery phase (p = 0.04). There were no differences in intraoperative times and patient outcomes. These results demonstrate the impact of COVID-19 related delays to our cohort, however due to the retrospective nature of this study, the current results need to be backed up by higher evidence in order for strong recommendations to be made.

A Retrospective Study on the Impact of COVID-19 on Emergency General Surgery.

Background The coronavirus pandemic has caused global disruption to all aspects of life. This disturbance has been most notable in the medical world. Political, societal, medical, and behavioral alterations have forced emergency surgical practices to adapt. This study investigated the impact of coronavirus 2019 (COVID-19) at a busy surgical center. Methodology This is a retrospective observational study. Three study periods were analyzed: pre-COVID, first wave, and second wave. Data were collected on referrals, diagnoses, investigations, management pathways, outcomes, patient behavior, and consultant practice. A one-way analysis of variance (ANOVA test) was used for the analysis of parametric data and the Mann-Whitney U test for non-parametric data. Results Declining numbers of patients presented across the three periods. There was a severe disruption in performing emergency general surgeries during the first wave, propagated by alterations in clinical decision-making, as well as fluctuations in societal and patient behavior. Despite the effects of the second wave being significantly more profound in terms of hospitalization and COVID-related mortality, a paradoxical, gradual return to the norm was noted, which was seen in referral pathways, imaging decisions, and management strategies. Conclusion Our data is suggestive of society, both within and outside the medical sphere, adjusting to life with COVID-19.

Surgical Adjuncts to Rhinoplasty: An Algorithmic Approach.

BACKGROUND: Nasal aesthetics can be significantly affected by the interdependence of the surrounding bone and soft tissues of the face. These include the maxilla, septum, frontal bone, mandible, and the soft tissues and cartilage surrounding the nose. Therefore, it is pertinent to analyze and address these critical relationships of the nose in order to achieve a successful rhinoplasty. This work seeks to describe the battery of adjunct procedures available to supplement a rhinoplasty. Furthermore, each preoperative finding or indication for the adjunct is described in an algorithmic fashion. METHODS: A literature search using PubMed, Google Scholar, and a university library database was performed to locate papers describing adjunctive procedures to rhinoplasty. Indications and preoperative analysis were extracted from each paper. If the indication or finding was unclear, supplementary literature describing rhinoplasty and adjunctive analysis were sought in order to supplement our findings. RESULTS: Sixteen papers in total described adjunctive procedures for rhinoplasty. Each work highlighted a procedure or set of procedures on a surrounding facial feature including the forehead, brow, cheeks, lips, and chin, and neck. In total, 13 adjunct procedures for rhinoplasty are described with their respective indications. Additional literature and techniques were researched to clarify indicated procedures. CONCLUSION: The ability to correctly understand the critical relationships of the nose can help the surgeon correctly recognize the indication for a rhinoplasty adjunct procedure, leading to better aesthetic balance and surgical outcomes. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Machine Learning and Feature Selection Applied to SEER Data to Reliably Assess Thyroid Cancer Prognosis.

Utilizing historical clinical datasets to guide future treatment choices is beneficial for patients and physicians. Machine learning and feature selection algorithms (namely, Fisher's discriminant ratio, Kruskal-Wallis' analysis, and Relief-F) have been combined in this research to analyse a SEER database containing clinical features from de-identified thyroid cancer patients. The data covered 34 unique clinical variables such as patients' age at diagnosis or information regarding lymph nodes, which were employed to build various novel classifiers to distinguish patients that lived for over 10 years since diagnosis, from those who did not survive at least five years. By properly optimizing supervised neural networks, specifically multilayer perceptrons, using data from large groups of thyroid cancer patients (between 6,756 and 20,344 for different models), we demonstrate that unspecialized and existing medical recording can be reliably turned into power of prediction to help doctors make informed and optimized treatment decisions, as distinguishing patients in terms of prognosis has been achieved with 94.5% accuracy. We also envisage the potential of applying our machine learning strategy to other diseases and purposes such as in designing clinical trials for unmasking the maximum benefits and minimizing risks associated with new drug candidates on given populations.

Safe autologous rib harvest in patients with breast implants; technique and review.

INTRODUCTION: Autologous rib harvest is a useful technique for rhinoplasty when septal cartilage is inadequate. For patients who have previously undergone augmentation mammoplasty, however, there is theoretical concern about the risk to breast implant integrity during costal cartilage harvest. The true risk to patients and their implants from autologous rib harvest is poorly studied. Herein, we review our technique and experience with autologous rib harvest after augmentation mammoplasty. METHOD: We performed a retrospective review of patients who underwent autologous rib harvest after augmentation mammoplasty between February 1998 and February 2017 at a tertiary care hospital and private practice. We identified basic demographics, implant type, approach to implantation, and any post-operative complications following rib harvest. Surgery was performed using an inframammary approach with a boat-technique for cartilage harvest. RESULTS: A total of 109 individuals, aged 19-64, were included in our study. There was a 2% rate of post-operative seroma development; no patients developed long-term complications. There was a 5% rate of incidental intraoperative discovery of implant dehiscence or implant entry, all of which were repaired primarily at the time of surgery, and none of which developed post-operative sequelae. There were no cases of pneumothorax, post-operative breast malposition, or other major complications. CONCLUSION: Herein, we present the largest cohort of patients to undergo autologous rib harvest after augmentation mammoplasty. Routine intra-operative drain placement and perioperative imaging is unnecessary. Our technique allows harvest of a suitable amount of cartilage, is very cosmetically acceptable to this cosmetically-conscious population, and is safe for patients and their implants.

Management of Facial Scars.

Scarring is a natural process of healing after damage to the skin that extends to the reticular dermis. While some scars may be socially acceptable, even admirable, scars of the face can be viewed as disfiguring or ugly. Minimizing the appearance of facial scars and optimizing their cosmetic outcome ideally begin before surgery or, in the cause of trauma, at the initial reconstruction. Even when there has been poor initial healing, a scar's appearance can be improved. Herein, we review conservative, medical, and surgical therapies to improve the appearance of facial scars.

Pharyngeal Reconstruction with Microvascular Free Tissue Transfer.

Reconstruction of pharyngoesophageal defects after total laryngectomies and extirpation of hypopharyngeal and upper esophageal carcinomas presents a challenging task. Goals of reconstruction include adequate voice rehabilitation and restoration of normal swallowing. The reconstructive armamentarium contains many options for reconstruction and creation of a new upper digestive tract. This review article focuses on the most commonly used free tissue transfer options for the reconstruction of these defects, with an assessment of their advantages and disadvantages.

Wrap choice during fundoplication.

Gastro-oesphageal reflux disease is an increasing health burden. The mainstay of treatment has conventionally been medical therapy but since the introduction of laparoscopic surgery laparoscopic anti-reflux surgery has been increasingly used for intractable symptoms or in patients unwilling to take long term medication. The Nissen 360 degree wrap has traditionally been considered the gold standard operation but can be associated with significant complications. These complications include "gas bloat" and dysphagia and can occur relatively frequently. Various modifications have been described to the original operation and some of these have been described. In addition alternative wraps have been described which seem to have a reduced incidence of complications associated with their use. This editorial discusses the various types of wrap that can be performed and the minimum requirements of the surgical technique. The evidence from a recent meta-analysis of the randomised data has suggested that an anterior wrap is associated with a lower rate of complications and gives just as good control of reflux symptoms. The advantages and disadvantages of an anterior wrap are discussed. The lack of long term follow up data concerns some practitioners and at the moment the choice of wrap carried out still rests with the individual surgeon.

Temporoparietal Fascia Free Flap for Nasoseptal Perforation Repair.

Nasoseptal perforations can be a challenging defect for the reconstructive surgeon, with repair limited by the surrounding tissue availability and the defect size. In patients with a history of cocaine use, often the integrity of surrounding vasculature is questionable and large defects may not be well suited for local reconstruction. In the otolaryngology literature, several reconstructive options using local tissue and synthetic materials have been described, but there have been no reports of microvascular free flaps utilized in this regard. We present a unique case of a 37-year-old woman with a 3.0 cm × 3.5 cm nasoseptal perforation secondary to cocaine use successfully reconstructed with a temporoparietal fascia free flap anastomosed to the facial artery and vein. Postoperatively, the patient had a well-healed septal defect from the free flap reconstruction This new technique shows promise as a feasible option for patients with large defects and for those with limited local reconstructive options. The ease of harvest and low donor-site morbidity make the temporoparietal fascia flap a suitable option for repair of complex nasoseptal defects.

Acute pancreatitis: current perspectives on diagnosis and management.

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Contemporary Trends in the Management of Posttraumatic Cerebrospinal Fluid Leaks.

The objective of this review is to provide an overview on the diagnosis and management of traumatic cerebrospinal fluid (CSF) leaks. This comprehensive review explores controversies associated with the management of CSF leaks as well as a review of the most contemporary literature. The scope of this article covers both traumatic CSF leaks of the middle and anterior cranial fossae.

Calvarial Reconstruction.

Calvarial reconstruction is a challenge to reconstructive surgeons, especially considering protection of intracranial contents. In recent years, the advent of multiple reconstructive materials adds tools to the surgical armamentarium. Options include autologous split calvarial and rib grafts and alloplastic materials such as titanium mesh, methyl methacrylate, calcium hydroxyapatite, and polyetheretherketone. The most important aspect of cranial reconstruction still lies in finding the most aesthetic, safe, and reliable means of filling a defect.

Complications of Skull Base Surgery.

Approaches to surgical management of skull base pathology and reconstruction of skull base defects have evolved over the past several decades. The goal, however, remains the same-to effectively address the pathology with minimal complications. In this article, the authors try to explore multiple complications of skull base surgery, discussing their incidence, natural course, and prevention. This will prove beneficial in optimal management of patients with a myriad of skull base disorders.

Colonic Perforation: A Medical Complication.

Hypothyroidism is a common comorbidity that on acute presentation is often overlooked. It can be an easily managed condition; however non-compliance can have severe consequences. In the presented case it was requirement for emergency surgery that resulted in stoma formation. This case is a first example of the need to include patient's decision making process with regards to medication adherence in the setting of chronic disease.

Pancreatitis: Preventing catastrophic haemorrhage.

Pancreatitis represents nearly 3% of acute admissions to general surgery in United Kingdom hospitals and has a mortality of around 1%-7% which increases to around 10%-18% in patients with severe pancreatitis. Patients at greatest risk were those identified to have infected pancreatic necrosis and/or organ failure. This review seeks to highlight the potential vascular complications associated with pancreatitis that despite being relatively uncommon are associated with mortality in the region of 34%-52%. We examine the current evidence base to determine the most appropriate method by which to image and treat pseudo-aneurysms that arise as the result of acute and chronic inflammation of pancreas. We identify how early recognition of the presence of a pseudo-aneurysm can facilitate expedited care in an expert centre of a complex pathology that may require angiographic, percutaneous, endoscopic or surgical intervention to prevent catastrophic haemorrhage.

Surgical management of temporal bone osteoradionecrosis: Single surgeon experience of 47 cases.

PURPOSE: To report the outcomes of 47 patients with temporal bone osteoradionecrosis treated primarily with surgical resection in order to analyze whether flap type and hyperbaric oxygen use affect wound breakdown. MATERIALS AND METHODS: Between January 1998 and January 2016, 47 patients were treated for temporal bone osteoradionecrosis with surgery. Some patients were also treated with hyperbaric oxygen. Resection of grossly necrotic temporal bone was followed by immediate reconstruction with local, regional, or free flaps. Minimum follow-up was 6months. If patients had breakdown of their initial reconstructions, secondary reconstruction was performed with either a regional or free flap. During the post-operative period, wound breakdown, flap complications, and patient survival were noted. RESULTS: 30 patients developed ORN from primary radiotherapy while 17 had post-operative radiation. It was found that wound breakdown was significantly associated with type of flap reconstruction (p=0.02) with local flap reconstruction portending a poorer prognosis. Hyperbaric oxygen was not associated with decreased wound breakdown (p=0.5). CONCLUSIONS: Surgical treatment can be an effective treatment for temporal bone osteoradionecrosis, without hyperbaric oxygen providing any additional benefit. Reconstruction with regional or free flaps may be a more reliable method to resurface defects compared to local flaps.

Epidemiological Trends of Head and Neck Cancer in the United States: A SEER Population Study.

PURPOSE: This study represents the most recent epidemiologic trends of head and neck cancer (HNC) in the United States. It provides an important discussion on oropharyngeal cancer and cancers related to the human papillomavirus. The objective was to identify trends in HNC (2002 to 2012) within the United States. MATERIALS AND METHODS: This study is a retrospective analysis of the US National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) submission. Using the November 2014 submission of the SEER database and SEER-18 data files, data from 2002 to 2012 were analyzed to determine the most recent epidemiologic trends. HNCs of all subtypes were analyzed together. Laryngeal cancers were further analyzed separately. Oropharyngeal cancers of the base of tongue and tonsil were analyzed independently to attempt to trend HPV-related cancers. RESULTS: From 2002 to 2012, there were 149,301 cases of HNC recorded in the SEER database. The HNC rate decreased by 0.22% per year (P = .0549) and the rate of laryngeal cancer decreased by 1.9% per year (P < .0001). The rate of oropharyngeal (HPV-related) cancer increased by 2.5% per year (P < .0001). HNC rates increased significantly in Kentucky and Connecticut and decreased in California (P < .05). HPV-related cancers increased significantly in all states except Georgia, Hawaii, and Michigan (P < .05). Laryngeal cancer rates decreased in California, Georgia, New Jersey, and New Mexico (P < .05). CONCLUSIONS: The overall incidence of HNC is decreasing in the United States. There is an increasing incidence of HPV-related cancers of the oropharynx. Meaningful differences in cancer incidence and rate of change exist between men and women. Furthermore, younger groups have a greater decrease of overall HNC, with an overall increase in HPV-related cancer in patients older than 50 years.