Management of complex acute biliary disease for the general surgeon: A narrative review.

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

Improving the management and outcomes of complex non-pedunculated colorectal polyps at a regional hospital in British Columbia.

BACKGROUND: Colorectal cancer arises from precancerous lesions, primarily adenomatous and serrated polyps. Some polyps pose significant technical endoscopic challenges due to their size, location, and/or morphology. A standardized protocol for documentation and management of these polyps can optimize clinical outcomes. METHODS: A Quality Improvement project compared patients with a complex polyp (non-pedunculated, > 2 cm), for 12 months prior and 12 months after protocol introduction. Documentation and polyp management details were compared pre- and post-implementation using the Chi-square test. RESULTS: 69 patients were diagnosed with complex polyps prior to the protocol introduction and 72 after. 79% (112/141) of patients underwent endoscopic mucosal resections (EMR) locally, and 14.9% (21/141) underwent surgery locally. After protocol introduction, there was significant improvement in documentation of suspicious appearing polyps (21.7% to 47.2%, P = 0.001), luminal circumference (14.5% to 34.7%, P = 0.005), and management plans (87.0% to 97.2%, P = 0.023); other elements of documentation were similar. The number of patients reviewed at multidisciplinary conference (MDC) increased from 1 to 61% (P < 0.005). Patients rebooked in a 1 h endoscopy time slot increased from 19 to 58% (P < 0.005), as did specific consent for EMR from 22 to 57% (P < 0.005). Among patients with polyps 3 cm or greater (23 pre, 36 post), MDC review increased from 4 to 67% (P < 0.005), primary polypectomy decreased from 72 to 23% (P = 0.001), patients rebooked in a double endoscopy slot increased from 33 to 75% (P = 0.005), and specific consent increased from 39 to 75% (P = 0.014). There were less polyp recurrences (12/42 pre and 1/50 post) among the post-protocol cohort (P < 0.001). CONCLUSIONS: The introduction of a formalized protocol for complex polyp adjudication and management has led to improved documentation, multidisciplinary discussion, and optimal complex polyp management with dedicated time for EMR, particularly for polyps over 3 cm. There is room for improvement, and this can be approached in a collaborative manner.

A distinct case of an 8-year-old female with cyclic neutropenia presenting with C. septicum abdominal sepsis and myonecrosis requiring a bowel resection and leg fasciotomy.

Clostridium septicum is a very rare cause of severe spontaneous pediatric enterocolitis and is often associated with underlying malignancy or immunocompromise. Likewise, cyclic neutropenia is a rare congenital immunodeficiency that is characterized by cyclical periods of neutropenia, often with more severe symptoms in the pediatric population. Here, we present a unique case of spontaneous C. septicum enterocolitis, sepsis, and myonecrosis in a child with undiagnosed cyclic neutropenia. Early recognition of pediatric sepsis, frequent reevaluation and identification of rapidly progressive infection, and early surgical intervention are critical for the effective management of a rare and severe infection.

The effect of preoperative oral nutritional supplementation on surgical site infections among adult patients undergoing elective surgery: A systematic review and meta-analysis.

INTRODUCTION: Mixed findings are reported on the effect of oral nutritional supplements in reducing Surgical Site Infections (SSIs). MATERIAL AND METHODS: PubMED, EMBASE and Cochrane were searched. Studies from inception to July 2022 were included if they involved adults undergoing elective surgery and compared preoperative macronutrient oral nutritional supplements to placebo/standard diet. RESULTS: Of 372 unique citations, 19 were included (N â€‹= â€‹2480): 13 RCTs (N â€‹= â€‹1506) and 6 observational studies (N â€‹= â€‹974). Moderate-certainty evidence suggested that nutritional supplements SSI risk (OR 0.54, 95% C.I. 0.40-0.72, N â€‹= â€‹2718 participants). In elective colorectal surgery, this risk-reduction was 0.43 (95% C.I. 0.26-0.61, N â€‹= â€‹835 participants) and among patients who received Impact 0.48 (95% C.I. 0.32-0.70, N â€‹= â€‹1338). CONCLUSION: Oral nutritional supplements prior to adult elective surgery may significantly reduce SSIs, with an overall 50% protective effect. This protective effect persisted in subgroup analysis of colorectal surgery patients and the use of Impact.

Nipple margin assessment at the time of nipple-sparing mastectomy.

BACKGROUND: Documenting negative margins at the nipple-areolar complex (NAC) during nipple-sparing mastectomy (NSM) remains the standard, but how to achieve this and how to manage a positive margin is debated. We sought to review nipple margin assessments at our institution and to analyze the risk factors of a positive margin and rate of local recurrence. METHODS: Patients who underwent NSM between 2012 and 2018 were reviewed and divided into 3 groups based on indication - cancer, contralateral prophylactic mastectomy (CPM) and bilateral prophylactic mastectomy (BPM). RESULTS: Nipple-sparing mastectomies were performed on 337 patients; 72% for cancer, 20% for CPMs and 8% for BPMs. Nipple margin assessments were performed in 87.8% of patients; 10 patients (3.4%) had a positive margin, 7 of whom underwent NAC excision and 3 were managed with observation. CONCLUSION: As indications for NSM increase, assessment of nipple margin provides valuable information to manage the NAC in patients with cancer. The routine use of nipple margin biopsies in patients undergoing CPM and BPM may no longer be required, as rates of occult malignant disease are low with no positive biopsies. Further studies with larger sample sizes are needed.

Surgical resection of a subphrenic endometrial stromal sarcoma metastasis tethered to diaphragm and liver in a 28-year-old patient: a case report.

Endometrial stromal sarcomas are the second most common type of mesenchymal uterine tumors, and they represent 1% of all uterine malignancies. Metastasis of this tumor occurs in about one third of patients, usually to the pelvis and lower genital tract. Metastases to the diaphragm or liver are exceedingly rare, with only a few published cases in the literature. This case presents a 28-year-old woman with a subphrenic endometrial stromal sarcoma metastasis between the right diaphragm and segment IVa of the liver that was treated with surgical resection.

A rare case of a congenital pancreatic duplication cyst in an infant complicated by an upper GI bleed, pancreatitis, cyst infection and gastric outlet obstruction.

Enteric duplication cysts are rare congenital entities most commonly found in the esophagus, ileum or colon but can be in remote locations such as the biliary tree, liver or pancreas. Pancreatic duplication cysts are very uncommon and usually present in adulthood with pancreatitis or abdominal pain. Here, we present a unique and complex case of an infant with a pancreatic duplication cyst initially presenting with an upper gastrointestinal bleed followed by pancreatitis, cyst infection and gastric outlet obstruction.

Pancreas tail adenocarcinoma tumor size is highly predictive of positive margins after a nonradical resection.

BACKGROUND: Radical resection (RAMPS) of left sided pancreatic ductal adenocarcinoma (PDAC) is effective in achieving R0 margins; however, not universally accepted due to lack of improved survival. We hypothesized that only larger tumors lead to R1 in non-RAMPS procedures. METHODS: A retrospective review of charts between 2008 and 2020 was performed. The primary outcome was evaluating R0 resection based on left-sided tumors' size and location, and secondary outcomes were OS and DFS. RESULTS: Sixty-eight percent had R0 resection. R1 groups' tumors were larger (5.5 cm vs. 3.8 cm, p = 0.004) and had higher LVI involvement (p = 0.003). OS and DFS did not differ on multivariate analysis. Tumor size above 4 cm in the tail was associated with R1 (p = 0.01). CONCLUSIONS: Larger tumors in the tail, but not body were associated with R1, but not worse survival. Perhaps larger tumors in the tail are a surrogate marker of poor disease biology.

68Ga-DOTATATE-PET shows promise for diagnosis of recurrent or persistent medullary thyroid cancer: A systematic review.

BACKGROUND: Many patients with Medullary Thyroid Cancer (MTC) will have persistent or recurrent disease after surgery requiring lifelong surveillance with imaging and tumor markers. The objective of this study is to evaluate the efficacy of 68Ga-DOTATATE-PET (or 68Ga labelled equivalent radiopharmaceutical) versus 18F-FDG-PET for detecting persistent and/or metastatic recurrent MTC. METHODS: Relevant studies were identified by conducting searches in Embase and PubMed and five studies were included in the final review. RESULTS: Five studies investigated per-patient sensitivity of 18F-FDG-PET and 68Ga-DOTATATE-PET in MTC patients. Four studies investigated the correlation between calcitonin and number of lesions detected by 18F-FDG-PET and 68Ga-DOTATATE-PET, and three investigated the correlation between CEA and number of lesions detected by 18F-FDG-PET and 68Ga-DOTATATE-PET. There was no significant difference in number of lesions detected by 18F-FDG -PET compared with 68Ga-DOTATATE-PET. CONCLUSIONS: When compared directly to 18F-FDG-PET, there is a general trend towards favoring 68Ga-DOTATATE-PET in per-patient sensitivities, and incidence of lesion detection.

A unique case of free-floating gastric band tubing causing intraabdominal sepsis in a patient with locked-in syndrome secondary to Guillain-Barré syndrome.

Laparoscopic adjustable gastric banding is a known bariatric procedure that has largely fallen out of favor in our modern surgical era. Several case reports describe various complications secondary to gastric band slippage. Here we present a unique complication not related to gastric band slippage, but intraabdominal sepsis secondary to free-floating gastric band tubing after removal of the subcutaneous port in a patient with locked-in syndrome secondary to Guillain-Barré syndrome.

Evolving anatomy education strategies for surgical residents: A scoping review.

INTRODUCTION: Dedicated anatomy educational time in medical schools has decreased significantly, disproportionately affecting surgical residents. In this scoping review, we aim to consolidate existing evidence, describe ongoing research, and highlight future directions for surgical anatomy education. METHODS: Two independent investigators searched MEDLINE, EMBASE, and the Cochrane library, for educational interventions targeting anatomy knowledge in surgical residents. English articles until October 28, 2021, were reviewed. RESULTS: 1135 abstracts were considered, and 59 (5.2%) included. Agreement on inclusion was excellent (k = 0.90). The majority were single-cohort studies (53%) and prospective cohort studies (17%). The most common disciplines were General Surgery (17%) and Obstetrics and Gynecology (17%). DISCUSSION: Cadavers consistently produce positive knowledge gains and are heavily favored by residents. They remain the educational method to which new educational models are compared. New technologies do not yet match cadaver fidelity. Research showing knowledge translation from cadaver labs to patient outcomes remains limited.

The Breast Cancer Patient Experience of Telemedicine During COVID-19.

BACKGROUND: The COVID-19 pandemic has seen major shifts in the delivery of health care across the world, including adoption of telemedicine. We present a survey of patient experience with telemedicine for the treatment of breast cancer. METHODS: A questionnaire designed to assess patient satisfaction with telemedicine was distributed to all patients who underwent surgery at the Providence Breast Centre (PBC) for breast cancer or benign/high-risk lesions with surgery follow-up dates between October 13 and December 31, 2020. Surveys were conducted via phone or at in-person follow-ups. RESULTS: A total of 123 of 172 (72%) eligible patients completed the survey; 85% of these patients enjoyed their telemedicine consultation, 93% found there was enough time for dialogue, 66% would choose to have a telemedicine consultation again, 79% would recommend telemedicine at PBC to a friend or family member, and 92% found Zoom© easy to use. When asked whether they prefer a telemedicine initial consultation over an in-person, 28% of patients agreed. When patients are analyzed according to their home address, those more than 10-km away from PBC prefer telemedicine over in-person appointments (37%) more often than those who live less than 10-km away (23%) (p = 0.045). CONCLUSIONS: Patients report a high level of satisfaction with telemedicine. It may be worthwhile to continue telemedicine beyond the pandemic era, due to its convenience, efficiency, and low-cost while keeping patients, physicians, and office staff safe. It also may be more useful in large geographic areas, such as British Columbia to increase access to care.

COVID-19 and breast cancer at a Regional Breast Centre: our flexible approach during the pandemic.

PURPOSE: In British Columbia (BC), there have been 2790 confirmed COVID-19 cases as of June 20, 2020. The aim of this project is to capture the effect of COVID-19 on the volume of surgery and adaptations to the surgical care of patients at a breast centre in BC. METHODS: All proven or suspected breast cancer cases treated with surgery between March 16, 2019 and April 30, 2019 and March 16, 2020 and April 30, 2020 through the Providence Breast Centre were included in this review. The date ranges in 2020 mark the early COVID-19 pandemic period in BC and the large shift in operating room access during this time. RESULTS: In 2019, 99 patients underwent surgery for proven breast cancer and 30 patients for suspected breast cancer. In 2020, 162 patients underwent surgery for breast cancer and 34 for suspected breast cancer. Wait times from core biopsy to surgery and surgery to oncology consultation were improved in 2020 with a reduction of core biopsy to surgery time from 58 to 28 days for patients seen during the pandemic. There was an increased use of regional anesthesia and same day discharge compared to 2019 with increases in regional anesthesia (41%-89%) and same day discharge (64%-86%) after adaptations to the pandemic were implemented. CONCLUSIONS: Changes such as improved access to telemedicine, timing for cancer surgeries, and safer anesthetic techniques in response to the pandemic will change breast cancer surgical care beyond the pandemic era. Centralization and team-based care is the way forward.