Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey.

BACKGROUND: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. METHODS: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. RESULTS: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. CONCLUSIONS: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. TRIAL REGISTRATION: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020.

Jejunal stenosis as a sequela after laparoscopic sleeve gastrectomy for morbid obesity: a case series.

Porto-mesenteric venous thrombosis (PMVT) is a rare complication that is encountered in less than 1% of patients following laparoscopic sleeve gastrectomy (LSG). This condition could be conservatively managed in stable patients with no evidence of peritonitis or bowel wall ischemia. Nonetheless, conservative management may be followed by ischemic small bowel stricture, which is poorly reported in the literature. Herein, we present our experience regarding three patients who presented with manifestations of jejunal stricture after initial successful conservative management of PMVT. Retrospective analysis of patients who developed jejunal stenosis as a sequela after LSG. The three included patients had undergone LSG with an uneventful post-operative course. All of them developed PMVT that was conservatively managed mainly by anticoagulation. After they were discharged, all of them returned with manifestations of upper bowel obstruction. Upper gastrointestinal series and abdominal computed tomography confirmed the diagnosis of jejunal stricture. The three patients were explored via laparoscopy, and resection anastomosis of the stenosed segment was performed. Bariatric surgeons should be aware of the association between PMVT, following LSG, and ischemic bowel strictures. That should help in the rapid diagnosis of the rare and difficult entity.

Laparoscopic approach in the management of diaphragmatic eventration in adults: gastrointestinal surgical perspective.

The current literature is poor with studies handling the role of laparoscopy in managing diaphragmatic eventration (DE). Herein, we describe our experience regarding the role of laparoscopy in managing DE patients presenting mainly with gastrointestinal symptoms. We retrospectively reviewed the data of 20 patients who underwent laparoscopic diaphragmatic plication between January 2010 and December 2018. Postoperative outcomes and quality of life were assessed. Most DEs were left sided (95%). Laparoscopic diaphragmatic plication was possible in all patients, along with correcting all associated gastrointestinal and diaphragmatic problems. The former included gastric volvulus (60%), reflux esophagitis (25%), cholelithiasis (5%), and pyloric obstruction (5%), while the latter included diaphragmatic and hiatus hernia (10% and 15%, respectively).The average operative time was 142 min. All patients had a regular (reviewer #1) postoperative course except for one who developed hydro-pneumothorax. At a median follow-up of 48 months, midterm outcomes were satisfactory, with an improvement (reviewer #1) in gastrointestinal symptoms. Three patients (reviewer #1) developed radiological recurrence without significant clinical symptoms. Patient's quality of life, including all parameters, significantly improved after the laparoscopic procedure compared to the preoperative values. Laparoscopic approach is safe and effective for managing adult diaphragmatic eventration (reviewer #1).

Clinicopathological features and management of biliary cystic tumors of the liver: a single-center experience.

BACKGROUND: Biliary cystic neoplasms (BCNs) of the liver are rare pathologies encountered in hepatobiliary surgeries. Till now, there is a lack of definitive criteria used to differentiate biliary cystadenoma (BCA) from biliary cystadenocarcinoma (BCAC). METHODS: In the period between 2005 and 2018, the data of consecutive patients diagnosed with BCA and BCAC were retrospectively reviewed. RESULTS: A total of 62 patients underwent surgical management for BCNs. BCA was diagnosed in 50 patients while 12 patients had BCAC. Old age, male gender, smoking, and abdominal pain were strongly associated with BCAC. Left lobe location, small size, with the presence of mural nodule, and solid component were significantly noticed with BCAC. A novel pre-operative score was developed to predict the susceptibility for BCAC and help us to identify the optimal surgical strategy. Blood loss, operative time, and complications were comparable between the two study groups. CONCLUSION: Mural nodules or solid components are suggestive of BCAC. Complete surgical resection of cystic tumors of the liver is mandatory due to malignant potential of the lesion and for prolonged survival.

Gastrointestinal stromal tumors of the small intestine: the challenge of diagnosis and the outcome of management.

PURPOSES: Gastrointestinal stromal tumor (GIST) is a rare small intestinal tumor. Most patients usually report long-period complaints due to difficult diagnoses. A high grade of suspicion is required for early diagnosis and initiation of the proper management. METHODS: A retrospective study of all patients with small intestinal GIST who were operated in the period between January 2008 and May 2021 at Mansoura University Gastrointestinal Surgical Center (GIST). RESULTS: Thirty-four patients were included in the study with a mean age of 58.15 years (± 12.65) with a male to female ratio of 1.3:1. The mean duration between onset of symptoms and diagnosis was 4.62 years (± 2.34). Diagnosis of a small intestinal lesion was accomplished through abdominal computed tomography (CT) in 19 patients (55.9%). The mean size of the tumor was 8.76 cm (± 7.76) ranging from 1.5 to 35 cm. The lesion was of ileal origin in 20 cases (58.8%) and jejunal in 14 cases (41.2%). During the scheduled follow-up period, tumor recurrence occurred in one patient (2.9%). No mortality was encountered. CONCLUSION: Diagnosis of a small bowel GISTs requires a high grade of suspicion. Implementing new diagnostic techniques like angiography, capsule endoscopy, and enteroscopy should be encouraged when suspecting these lesions. Surgical resection is always associated with an excellent postoperative recovery profile and very low recurrence rates.

Long-Term Outcomes of Laparoscopic Gastric Plication for Treatment of Morbid Obesity: a Single-Center Experience.

BACKGROUND: Although laparoscopic gastric plication (LGP) has been mentioned in many studies, its practice has not yet been standardized. In addition, the outcomes remain conflicting, especially long-term ones. This study was conducted to elucidate the long-term consequences of LGP. METHODS: Retrospective analysis of patients with obesity underwent LGP at our institution between March 2010 and September 2014. Data were prospectively collected from our database. RESULTS: Of the 88 consecutive patients in the study period between 2010 and 2014, follow-up data out to 6 years was available in 60 LGP patients (68.18%). The mean age of the included patients was 41.3 ± 10 years. A total of 81.7% were females. We observed a significant BMI reduction out to 2 years (p < 0.001), a plateau at 3 and 4 years, and a significant BMI increase at 6 years (p < 0.01). %TWL at 2 years was 21.14% and 12.08% at 6 years. Weight regain was observed in 35 patients at 6 years to reach a rate of 58.3%. Predictors for weight regain at 6 years were disrupted plication fold, increased hunger, and non-adherence to regular exercise. The diabetes improvement rate was 66.6% at 6 years. There were 14 re-operations (23.3%): 1 emergency (1.6%) and 13 (21.6%) elective. There was no mortality. CONCLUSION: At the 6-year follow-up visit, LGP has a much less durable effect on weight loss with a % EWL of 32% and a weight regain of 58.3% resulting in a high rate of revisions.

Effect of Altitude Level on Surgical Outcomes of Laparoscopic Sleeve Gastrectomy for Patients With Morbid Obesity: A Multicentre Prospective Study.

BACKGROUND: This study aimed to evaluate the impact of altitude level on surgical outcomes of laparoscopic sleeve gastrectomy (LSG) for patients with morbid obesity. METHODS: At the normal altitude level, 808 patients underwent LSG, and 467 patients underwent LSG in high-altitude regions. The primary outcome was evaluated based on the postoperative morbidity rate. Secondary outcomes were evaluated based on operating time, mortality, hospital stay, percentage of total weight loss (TWL), and comorbidities improvement. RESULTS: No significant differences were noted in-hospital stay, time to start oral intake, gastric leakage, overall complications, and hospital mortality between the 2 groups. Deep vein thrombosis, pulmonary embolism, and mesenteric vascular occlusion were significantly higher in high altitude [11 (1.3%) vs. 14 (3%), P=0.04; 8 (0.7%) vs. 11 (2.4%), P=0.01; 4 (0.5%) vs. 8 (1.7%), P=0.03, respectively]. Patients with normal altitude recorded a better %TWL than those at high altitude after 12 months (41±9 vs. 39±9.6, P=0.002) and after 24 months (41±8 vs. 40±9, P=0.009). In both groups, a significant improvement was noted in comorbidity after LSG. CONCLUSION: The %TWL significantly achieved with LSG in normal and high altitudes. After 12 and 24 months, the %TWL is significantly higher with LSG at normal altitudes. High altitude is associated with a high incidence of deep vein thrombosis, pulmonary embolism, and superior mesenteric vascular occlusion with LSG.

Single-Anastomosis Sleeve Ileal (SASI) Bypass: Hopes and Concerns after a Two-Year Follow-up.

BACKGROUND: Single-anastomosis sleeve ileal (SASI) bypass is a simplification of sleeve gastrectomy with transit bipartition. Both share a metabolic foundation through early postprandial ileal brake, and SASI bypass has the advantages of shorter operative time and less incidence of internal herniation. This study evaluates the safety and outcome of SASI bypass with 2-year follow-up. METHODS: A retrospective cohort study of all patients who underwent SASI bypass in the period between June 2016 and January 2019. The primary outcome was weight loss and diabetic remission. RESULTS: Three hundred twenty-two patients underwent SASI bypass with a mean age of 37.4 ± 15 years and a mean body mass index of 50.1 ± 7.7 kg/m2. Thirteen patients (4%) had early major postoperative complications. The 1-year percentage of excess weight loss (%EWL) was 86.9 ± 9.2, and diabetic remission rate was 98.2%. The 2-year %EWL was 96.7 ± 5, and diabetic remission rate was 97.9%. Twenty-six patients had gastroesophageal reflux that improved in 21 (80.7%) patients, remained stationary in 4 (15.4%) patients, and worsened in one patient who required reversal. One patient (0.3%) had severe protein-energy malnutrition and is prepared for reversal. Technical variations had no significant impact on %EWL or diabetic remission. CONCLUSION: SASI bypass had a promising outcome in terms of 2-year %EWL, diabetic remission, and improvement of preoperative GERD. However, stationary or progressive course of GERD is a substantial possibility. Although the double-outlet for the gastric content allows duodenal access, it may be an obstacle to the standardization of postoperative care. The double-outlet is not a guarantee for absence of malnutrition.

The Forgotten Element in the Resumption of Elective Bariatric Surgery During the COVID-19 Pandemic: the Patient Consent!

Safety comes first, and the sympathy with the postponed bariatric patients should not come at the expense of the proper standard of care. This study presents a survey of 266 bariatric candidates who were rescheduled for bariatric surgery after postponement during the COVID-19 pandemic. The aim was to assess their knowledge and expectations regarding bariatric surgery and the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A total of 233 (87.6%) candidates believed that they were prone to a higher risk of severe SARS-CoV-2 infection, and 24.4% of them believed that bariatric surgery, during the pandemic, would improve their immunity. A total of 27.8% of candidates attributed the responsibility regarding potential perioperative SARS-CoV-2 infection to the medical personnel, and 10.7% of them believed it to be the surgeon's responsibility.

Types, Safety, and Efficacy of Limb Distalization for Inadequate Weight Loss After Roux-en-Y Gastric Bypass: A Systematic Review and Meta-analysis With a Call for Standardized Terminology.

OBJECTIVE: Comprehensive classification and evaluation of the outcome of limb distalization (LD) for inadequate weight loss after roux-en-y gastric bypass (RYGB). BACKGROUND: Limb distalization is a revisional malabsorptive procedure for the management of inadequate weight loss after RYGB. Multiple studies with small sample sizes reported the outcome of LD. This meta-analysis aims to reach a higher level of evidence regarding the safety and efficacy of the procedure. METHODS: A systematic search, including all studies on LD for management of inadequate weight loss after RYGB. The search engines included were PubMed, Embase, Web of Science, Cochrane Library, Scopus, and EBSCOhost. RESULTS: Fourteen studies were included. The pooled estimates of the mid-term percentage of excess weight loss (%EWL), diabetic, and hypertension remission were 50.8%, 69.9%, and 59.8%, respectively. The rate of surgical revision for the management of protein-energy malnutrition (PEM) was 17.1%. The %EWL was significantly higher with older age and good response to index surgery (P = 0.01, 0.04, respectively). Less total alimentary limb length was not associated with better %EWL (P = 0.9), but it was significantly associated with severe PEM (P = 0.01). CONCLUSIONS: LD has an encouraging rate of resolution of comorbidities. A judicious patient selection is essential for better weight loss after LD. Type I LD with total alimentary limb length ≥350 cm was associated with less risk of malnutrition. PEM is a life-threatening complication that may require revisional surgery years after LD. Future studies on LD, adopting standardized surgical practice and terminology, will allow a more conclusive assessment of the outcome of the procedure.

Effect of Adding Hydrocortisone to Intraperitoneal Bupivacaine in Laparoscopic Bariatric Surgery.

BACKGROUND: Bariatric surgery is the effective management of obesity; however, postoperative pain is associated with a great morbidity. The management of pain is important for the enhancement of patient recovery. Local anesthetics can be injected during laparoscopic surgery into the peritoneum throughout the ports produced either before the beginning of laparoscopy or before the closure of the wound to reduce postoperative pain. Our aim is to evaluate if there is an additive analgesic effect by the administration of intraperitoneal hydrocortisone with streamed intraperitoneal bupivacaine as a method of postoperative pain relief in laparoscopic bariatric surgeries. PATIENTS AND METHODS: One hundred patients listed for laparoscopic bariatric surgery were the subject of this study. Patients were randomly allocated into two groups: Group I received 100 mg of 0.5% isobaric bupivacaine plus 20 mL normal saline intraperitoneally and Group II received intraperitoneal 100 mg of 0.5% isobaric bupivacaine + 100 mg hydrocortisone + 20 mL of saline at the end of the laparoscopic procedure. The primary outcome was the Visual Analog Scale (VAS) score for pain. The secondary outcomes were the time of first analgesic request, total opioid requirement, heart rate, and mean blood pressure. RESULTS: VAS showed a significant decrease at 4, 6, and 12 h postoperative in Group II compared to Group I. There was a marked decrease in total meperidine requirement with prolonged time of the first analgesic request in Group II compared to Group I. CONCLUSION: Intraperitoneal hydrocortisone with bupivacaine had improved postoperative pain relief with a decrease in analgesic requirement.

Gastric Stenosis After Sleeve Gastrectomy: an Algorithm for Management.

BACKGROUND: Gastric stenosis (GS) is a well-recognized complication after sleeve gastrectomy (SG) with a negative impact on patients' nutritional status and quality of life. There is no consensus on a validated, comprehensive management algorithm for GS. This study evaluates treatment modalities and proposes a management algorithm for obstructive gastric symptoms (OGSs) after SG. METHODS: This is a retrospective cohort study of patients with GS after SG between January 2013 and January 2019. Patients with concomitant GS and staple-line leak were excluded. The primary outcome was the clinical response to treatment. RESULTS: Forty-nine patients presented with OGSs. One patient underwent urgent surgical treatment for acute migration of cardia. Of 42 patients who had evident GS, pneumatic balloon dilatation (PBD) achieved clinical success in 28 (66.7%) patients. Six patients were diagnosed with indolent GS, and four of them improved after empirical PBD. The mean interval from index surgery to PBD was 5.3 (± 4.2) months. Longer duration of PBD session was associated with better clinical outcomes (5.8 ± 3.7 vs. 3.2 ± 1.7 min) (P = 0.017). After failed PBD, endoscopic stenting (n = 2) and revisional surgery (n = 7) were performed with clinical success in all patients. CONCLUSION: PBD using achalasia balloon is the mainstay of treatment with good clinical outcomes. The utility of endoscopic stenting for GS should be different from its use for leakage in aspects of dwelling time and required endoscopic expertise. RYGB is the gold standard revisional procedure due to the high success rate and technical familiarity. Controversial aspects of management require future prospective comparative studies.

Protein Energy Malnutrition After One-Anastomosis Gastric Bypass with a Biliopancreatic Limb ≤200 cm: A Case Series.

Background: Increased popularity of one-anastomosis gastric bypass (OAGB) is associated with increased reports on the procedure-related complications. Protein-energy malnutrition (PEM) is a serious complication that may mandate reversal. The primary outcome of this study is the outcome of surgical management of PEM after OAGB. Methods: A retrospective cohort study of patients presented with PEM after OAGB between January 2014 and December 2018. Patients with a biliopancreatic limb (BPL) >200 cm were excluded. PEM was diagnosed based on the Global Leadership Initiative on Malnutrition criteria. Indications for reversal of OAGB due to PEM included failure of conservative measures, intolerable symptoms, and hepatic decompensation. Results: Eight patients presented with PEM and were reversed to normal anatomy or Roux-en-Y gastric bypass. The incidence of postoperative 30-day complications in this series was 37.5% (n: 3/7). Postoperative mortality due to hepatic cell failure occurred in 1 patient. Two patients deceased before reversal, one secondary to severe soft tissue infection, whereas the cause of death could not be confirmed for the second. Conclusion: Socioeconomic status and thorough preoperative counselling are important to predict patient commitment to postoperative supplementations and laboratory investigations. Bariatric teams should apply innovative methods as telemedicine to make patient compliance easier. The etiology of PEM cannot be purely explained by the BPL length. Revisional surgery is mandatory for resistant, recurrent, or complicated PEM.

Outcome and Adverse Events of Endoscopic Bariatric Stents for Management of Leakage after Bariatric Surgery.

INTRODUCTION: Bariatric leakage (BL) is a serious complication with a variety in available treatment options. Endoscopic stenting is preferred because of its minimally invasive nature in morbidly obese patients. Various modifications have been applied to stents since its use in palliation of malignant strictures. Few studies have exclusively evaluated the efficacy of bariatric stents in management BL. METHODS: A retrospective cohort study of patients with BL managed by bariatric stents in the period between July 2014 and January 2019. The primary outcome was the clinical success in healing of leakage and secondary outcomes included adverse events (AEs), hospital stay and procedure-related mortality. RESULTS: Forty-five patients were included in this study. Clinical success occurred in 33 patients (73.3%). There was no stent-related mortality. The most frequent stent-related complications were reflux (62.2%), intolerance (55.6%), and migration (17.8%). Severe AEs occurred in 9 patients (20%). The overall complications rate was higher in diabetic patients (P = 0.048). Intolerance was significantly associated with shorter interval to management (P = 0.02). Stent migration was higher in male patients (P = 0.019) and higher BMI (P = 0.024). CONCLUSION: Endoscopic stenting is a double-edged weapon that must be handled cautiously. It is a highly effective therapy, and early intervention is the main determinant of its efficacy. But it is not a treatment without complications (80%). The variant and high prevalence of complications mandates a strict follow-up throughout the stenting duration.

Laparoscopic Pancreaticodudenectomy for Periampullary Tumor: Should it be a Routine? A Propensity Score-matched Study.

INTRODUCTION: Laparoscopic pancreaticoduodenectomy (LPD) is a complex and challenging procedure even with experienced surgeons. The aim of this study is to evaluate the feasibility and surgical and oncological outcomes of LPD compared with open pancreaticoduodenectomy (OPD). PATIENTS AND METHOD: This is a propensity score-matched analysis for patients with periampullary tumors who underwent PD. Patients underwent LPD and matched group underwent OPD included in the study. The primary outcome measure was the rate of total postoperative morbidities. Secondary outcomes included operative times, hospital stay, wound length and cosmosis, oncological outcomes, recurrence rate, and survival rate. RESULTS: A total of 111 patients were included in the study (37 LPD and 74 OPD). The conversion rate from LPD to OPD was 4 cases (10.8%). LPD provides significantly shorter hospital stay (7 vs. 10 d; P=0.004), less blood loss (250 vs. 450 mL, P=0.001), less postoperative pain, early oral intake, and better cosmosis. The length of the wound is significantly shorter in LPD. The operative time needed for dissection and reconstruction was significantly longer in LPD group (420 vs. 300 min; P=0.0001). Both groups were comparable as regards lymph node retrieved (15 vs. 14; P=0.21) and R0 rate (86.5% vs. 83.8%; P=0.6). No significant difference was seen as regards postoperative morbidities, re-exploration, readmission, recurrence, and survival rate. CONCLUSIONS: LPD is a feasible procedure; it provided a shorter hospital stay, less blood loss, earlier oral intake, and better cosmosis than OPD. It had the same postoperative complications and oncological outcomes as OPD.

Biliary leakage following pancreaticoduodenectomy: Prevalence, risk factors and management.

BACKGROUND: Few studies investigated biliary leakage after pancreaticoduodenectomy (PD) especially when compared to postoperative pancreatic fistula (POPF). This study was to determine the incidence of biliary leakage after PD, predisposing factors of biliary leakage, and its management. METHODS: We retrospectively studied all patients who underwent PD from January 2008 to December 2017 at Gastrointestinal Surgery Center, Mansoura University, Egypt. According to occurrence of postoperative biliary leakage, patients were divided into two groups. Group (1) included patients who developed biliary leakage and group (2) included patients without identified biliary leakage. The preoperative data, operative details, and postoperative morbidity and mortality were analyzed. RESULTS: The study included 555 patients. Forty-four patients (7.9%) developed biliary leakage. Ten patients (1.8%) had concomitant POPF. Multivariate analysis identified obesity and time needed for hepaticojejunostomy reconstruction as independent risk factors of biliary leakage, and no history of preoperative endoscopic retrograde cholangiopancreatiography (ERCP) as protective factor. Biliary leakage from hepaticojejunostomy after PD leads to a significant increase in development of delayed gastric emptying, and wound infection. The median hospital stay and time to resume oral intake were significantly greater in the biliary leakage group. Non-surgical management was needed in 40 patients (90.9%). Only 4 patients (9.1%) required re-exploration due to biliary peritonitis and associated POPF. The mortality rate in the biliary leakage group was significantly higher than that of the non-biliary leakage group (6.8% vs 3.9%, P = 0.05). CONCLUSIONS: Obesity and time needed for hepaticojejunostomy reconstruction are independent risk factors of biliary leakage, and no history of preoperative ERCP is protective factor. Biliary leakage increases the risk of morbidity and mortality especially if concomitant with POPF. However, biliary leakage can be conservatively managed in majority of cases.

Efficacy of octreotide in the prevention of complications after pancreaticoduodenectomy in patients with soft pancreas and non-dilated pancreatic duct: A prospective randomized trial.

BACKGROUND: The efficacy of octreotide to prevent postoperative pancreatic fistula (POPF) of pancreaticoduodenectomy (PD) is still controversial. This study aimed to evaluate the effect of postoperative use of octreotide on the outcomes after PD. METHODS: This is a prospective randomized controlled trial for postoperative use of octreotide in patients undergoing PD. Patients with soft pancreas and pancreatic duct < 3 mm were randomized to 2 groups. Group I did not receive postoperative octreotide. Group II received postoperative octreotide. The primary end of the study is to compare the rate of POPF. RESULTS: A total of 104 patients were included in the study and were divided into two randomized groups. There were no significant difference in overall complications and its severity. POPF occurred in 11 patients (21.2%) in group I and 10 (19.2%) in group II, without statistical significance (P = 0.807). Also, there was no significant differences between both groups regarding the incidence of biliary leakage (P = 0.083), delayed gastric emptying (P = 0.472), and early postoperative mortality (P = 0.727). CONCLUSIONS: Octreotide did not reduce postoperative morbidities, reoperation and mortality rate. Also, it did not affect the incidence of POPF and its clinically relevant variants.