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21: Early changes in immune cell metabolism and function are a hallmark of sleeve gastrectomy: a prospective human study
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Posted 04 Aug 2020

Early changes in immune cell metabolism and function are a hallmark of sleeve gastrectomy: a prospective human study
505 downloads medRxiv surgery

Tammy Lo, Eleanor J. M. Rudge, Robert P Chase, Renuka Subramaniam, Keyvan Heshmati, Elizabeth M. Lucey, Alison M. Weigl, Otatade J. Iyoha-Bello, Chelsea O. Ituah, Emily J. Benjamin, Seth W. McNutt, Leena Sathe, Leanna Farnam, Benjamin A. Raby, Ali Tavakkoli, Damien C. Croteau-Chonka, Eric G. Sheu

Objective To characterize longitudinal changes in blood biomarkers, leukocyte composition, and gene expression following laparoscopic sleeve gastrectomy (LSG). Background LSG is an effective treatment for obesity, leading to sustainable weight loss and improvements in obesity-related co-morbidities and inflammatory profiles. However, the effects of LSG on immune function and metabolism remain uncertain. Methods Prospective data was collected from 23 enrolled human subjects from a single institution. Parameters of weight, co-morbidities, and trends in blood biomarkers and leukocyte subsets were observed from pre-operative baseline to one year in three-month follow-up intervals. RNA-sequencing was performed on pairs of whole blood samples from the first six subjects of the study (baseline and three months post-surgery) to identify genome-wide gene expression changes associated with undergoing LSG. Results LSG led to a significant decrease in mean total body weight loss (18.1%) at three months and among diabetic subjects a reduction in HbA1c. Improvements in clinical inflammatory and hormonal biomarkers were demonstrated as early as three months after LSG. A reduction in neutrophil-lymphocyte ratio was observed, driven by a reduction in absolute neutrophil counts. Gene set enrichment analyses of differential whole blood gene expression demonstrated that after three months, LSG induced transcriptomic changes not only in inflammatory cytokine pathways but also in several key metabolic pathways related to energy metabolism. Conclusions LSG induces significant changes in the composition and metabolism of immune cells as early as three months post-operatively. Further evaluation is required of bariatric surgery's effects on immunometabolism and consequences for host defense and metabolic disease.

22: Study protocol for COvid-19 Vascular sERvice (COVER) study: The impact of the COVID-19 pandemic on the provision, practice and outcomes of vascular surgery
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Posted 29 May 2020

Study protocol for COvid-19 Vascular sERvice (COVER) study: The impact of the COVID-19 pandemic on the provision, practice and outcomes of vascular surgery
496 downloads medRxiv surgery

Vascular and Endovascular Research Network, Ruth A Benson, Dave C Bosanquet, Sandip Nandhra, Joseph Shalhoub, Athanasios Saratzis, Rachel Forsythe, Sarah Onida, George Dovell, Louise Hitchman, Nikesh Dattani, Ryan Preece, Graeme K Ambler, Christopher Imray

Background: The novel Coronavirus Disease 2019 (COVID-19) pandemic is having a profound impact on global healthcare. Shortages in staff, operating theatre space and intensive care beds has led to a significant reduction in the provision of surgical care. Even vascular surgery, often insulated from resource scarcity due to its status as an urgent specialty, has limited capacity due to the pandemic. Furthermore, many vascular surgical patients are elderly with multiple comorbidities putting them at increased risk of COVID-19 and its complications. There is an urgent need to investigate the impact on patients presenting to vascular surgeons during the COVID-19 pandemic. Methods and Analysis: The COvid-19 Vascular sERvice (COVER) study has been designed to investigate the worldwide impact of the COVID-19 pandemic on vascular surgery, at both service provision and individual patient level. COVER is running as a collaborative study through the Vascular and Endovascular Research Network (VERN) with the support of numerous national (Vascular Society of Great Britain and Ireland, British Society of Endovascular Therapy, British Society of Interventional Radiology, Rouleaux Club) and an evolving number of international organisations (Vascupedia, SingVasc, Audible Bleeding (USA), Australian and New Zealand Vascular Trials Network (ANZVTN)). The study has 3 Tiers: Tier 1 is a survey of vascular surgeons to capture longitudinal changes to the provision of vascular services within their hospital; Tier 2 captures data on vascular and endovascular procedures performed during the pandemic; and Tier 3 will capture any deviations to patient management strategies from pre-pandemic best practice. Data submission and collection will be electronic using online survey tools (Tier 1: SurveyMonkey for service provision data) and encrypted data capture forms (Tiers 2 and 3: REDCap for patient level data). Tier 1 data will undergo real-time serial analysis to determine longitudinal changes in practice, with country-specific analyses also performed. The analysis of Tier 2 and Tier 3 data will occur on completion of the study as per the pre-specified statistical analysis plan. Ethical Approval: Ethical approval from the UK Health Research Authority has been obtained for Tiers 2 and 3 (20/NW/0196 Liverpool Central). Participating centres in the UK will be required to seek local research and development approval. Non-UK centres will need to obtain a research ethics committee or institutional review board approvals in accordance with national and/or local requirements. ISRCTN: 80453162 (https://doi.org/10.1186/ISRCTN80453162) Ethical Approval: 20/NW/0196 Liverpool Central, IRAS: 282224

23: Bangla Technique of Laparoscopic Cholecystectomy: a Novel, Safe and Cost-effective modification of American and French Technique
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Posted 12 Oct 2020

Bangla Technique of Laparoscopic Cholecystectomy: a Novel, Safe and Cost-effective modification of American and French Technique
492 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Alak Nandy

BackgroundLaparoscopic cholecystectomy (LC) can be performed by following either of the two approaches proposed by the American and the French school. The two approaches have comparable operative times, but use different arrangements for the patients and operators positions, and sites for port insertions. The aim of the present paper is to describe an alternative to the American and the French approaches, referred to as the Bangla technique, which uses a standard four port approach but requires the presence of only one assistant along with the surgeon. It is hoped that the Bangla technique will improve surgery outcomes for gallbladder disease patients and encourage healthcare professionals in resource-poor settings to adopt minimally invasive/laparoscopic approaches to surgical problems. MethodsThe sample consisted of a total of 280 gallbladder disease retrospective observational cases (of which 21 were children between 6 and 16 years of age) who were treated with the Bangla technique at the South Point Hospital Chittagong, Bangladesh, between January 2018 and February 2020. ResultsSurgery data showed that using the Bangla technique, the average operating time and average operation theater time were36.25 and 45.9 minutes, respectively. Of the patients, 86% left the hospital on the same day of operation, while the remaining left the following day. In 91.7% of the cases, there were no complications, while content leakage and bleeding occurred in 6.7% and 1.4% cases, respectively. ConclusionThe proposed LC technique will benefit infection prevention and control by reducing the number of personnel in the operation theatre (one assistant and the surgeon) and, as such, reducing surgery-related expenses, which can be further decreased by using only one monitor. More so, the Bangla technique can be combined with the cystic artery sparing technique to reduce the risk of intraoperative bleeding and injury to the common bile duct.

24: Outcome of COVID-19 with co-existing surgical emergencies in children: our initial experiences and recommendations
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Posted 04 Aug 2020

Outcome of COVID-19 with co-existing surgical emergencies in children: our initial experiences and recommendations
475 downloads medRxiv surgery

Md Samiul Hasan, Md Ayub Ali, Umama Huq

Background: COVID 19 has changed the practice of surgery vividly all over the world. Pediatric surgery is not an exception. Prioritization protocols allowing us to provide emergency surgical care to the children in need while controlling the pandemic spread. The aim of this study is to share our experiences with the outcome of children with COVID 19 who had a co existing surgical emergency. Methods: This is a retrospective observational study. We reviewed the epidemiological, clinical, and laboratory data of all patients admitted in our surgery department through the emergency department and later diagnosed to have COVID 19 by RT PCR. The study duration was 3 months (April 2020 to June 2020). A nasopharyngeal swab was taken from all patients irrespective of symptoms to detect SARS CoV 2 by RT PCR with the purpose of detecting asymptomatic patients and patients with atypical symptoms. Emergency surgical services were provided immediately without delay and patients with positive test results were isolated according to the hospital protocol. We divided the test positive patients into 4 age groups for the convenience of data analysis. Data were retrieved from hospital records and analyzed using SPSS (version 25) software. Ethical permission was taken from the hospital ethical review board. Results: Total patients were 32. Seven (21.9%) of them were neonates. Twenty four (75%) patients were male. The predominant diagnosis was acute abdomen followed by infantile hypertrophic pyloric stenosis (IHPS), myelomeningocele, and intussusception. Only two patients had mild respiratory symptoms (dry cough). Fever was present in 13 (40.6%) patients. Fourteen (43.8%) patients required surgical treatment. The mean duration of hospital stay was 5.5 days. One neonate with ARM died in the postoperative ward due to cardiac arrest. No patient had hypoxemia or organ failure. Seven health care workers (5.51%) including doctors & nurses got infected with SARS Co V2 during this period. Conclusion: Our study has revealed a milder course of COVID 19 in children with minimal infectivity even when present in association with emergency surgical conditions. This might encourage a gradual restart to mitigate the impact of COVID 19 on children surgery. Keywords: COVID 19, COVID 19 in children, Children Surgery, Surgical emergency, Surgery in COVID 19 positive patients.

25: Impact of neoadjuvant chemoradiotherapy on postoperative clinically significant pancreatic fistula. A systemic review and updated meta-analysis.
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Posted 16 Dec 2020

Impact of neoadjuvant chemoradiotherapy on postoperative clinically significant pancreatic fistula. A systemic review and updated meta-analysis.
469 downloads medRxiv surgery

BHAVIN VASAVADA, HARDIK PATEL

Background: Pancreatic fistula is one of the main complications after pancreatic surgery and the leading cause of morbidity and mortality after pancreatic surgery. There are many pieces of evidence emerging out from retrospective studies and metanalysis that neoadjuvant chemoradiation decreases rates of clinically significant postoperative pancreatic fistula. Aims and objectives: The primary aim of our analysis was to do a systemic review and updated meta-analysis of literature published in the last 10 years and look for the association of neoadjuvant chemoradiation and risk of subsequent clinically significant pancreatic fistula. Methods: EMBASE, MEDLINE, and the Cochrane Database were searched for Studies comparing outcomes in patients receiving neoadjuvant chemoradiotherapy first with those patients who received surgery first in case of pancreatic cancer. A systemic review and Metanalysis were done according to MOOSE and PRISMA guidelines. Heterogeneity was measured using Q tests and I2, and p < 0.10 was determined as significant. The Odds ratios (OR) and Risk Ratios (RR) were calculated for dichotomous data as per the requirement, and weighted mean differences (WMD) were used for continuous variables. Nonrandomized trials were accessed for bias using the New Castle Ottawa scale. Publication bias was studied using funnel plots. The meta-analysis was conducted using Open Review Manager 5.4. Results: Twenty-six studies including 17021 patients finally included in the analysis. 339 patients out of a total of 3386 developed clinically significant pancreatic fistula in the neoadjuvant first group. 2342 patients out of 13335 patients developed clinically significant pancreatic fistula in the surgery first group. Neoadjuvant treatment significantly reduced the risk of subsequent clinically significant pancreatic fistula. (p= <0.0001). The number of patients with soft pancreas was significantly higher in the surgery first group. (p <0.0001). Pancreatic duct diameter mentioned in only two studies but there was no significant difference between both groups. [p=1].Blood loss was significantly more in the surgery first group.[ p <0.0001]. There was no difference in pancreaticoduodenectomy or distal pancreatectomy performed between both groups. (p=0.82). There was no difference in the number of borderline resectable pancreatic tumors between both groups. (p= 0.34). There was no difference in overall grade 3/grade 4 complications rate between both groups. (p= 0.39). Conclusion: Neoadjuvant treatments may be responsible for the lower rates of clinically significant pancreatic fistula after subsequent surgery.

26: Machine Learning Assisted Intraoperative Assessment of Brain Tumor Margins Using HRMAS NMR Spectroscopy
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Posted 26 Feb 2020

Machine Learning Assisted Intraoperative Assessment of Brain Tumor Margins Using HRMAS NMR Spectroscopy
465 downloads medRxiv surgery

Doruk Cakmakci, Emin Onur Karakaslar, Elisa Ruhland, Marie-Pierre Chenard, Francois Proust, Martial Piotto, Izzie Jacques Namer, A. Ercument Cicek

Complete resection of the tumor is important for survival in glioma patients. Even if the gross total resection was achieved, left-over micro-scale tissue in the excision cavity risks recurrence. High Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HRMAS NMR) technique can distinguish healthy and malign tissue efficiently using peak intensities of biomarker metabolites. The method is fast, sensitive and can work with small and unprocessed samples, which makes it a good fit for real-time analysis during surgery. However, only a targeted analysis for the existence of known tumor biomarkers can be made and this requires a technician with chemistry background, and a pathologist with knowledge on tumor metabolism to be present during surgery. Here, we show that we can accurately perform this analysis in real-time and can analyze the full spectrum in an untargeted fashion using machine learning. We work on a new and large HRMAS NMR dataset of glioma and control samples (n = 568), which are also labeled with a quantitative pathology analysis. Our results show that a random forest based approach can distinguish samples with tumor cells and controls accurately and effectively with a mean AUC of 85.6% and AUPR of 93.4%. We also show that we can further distinguish benign and malignant samples with a mean AUC of 87.1% and AUPR of 96.1%. We analyze the feature (peak) importance for classification to interpret the results of the classifier. We validate that known malignancy biomarkers such as creatine and 2-hydroxyglutarate play an important role in distinguish tumor and normal cells and suggest new biomarker regions. The code is released at http://github.com/ciceklab/HRMAS_NC.

27: Training surgery residents in underwater colonoscopies is more effective than training them in air-insufflation colonoscopies
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Posted 08 Jun 2020

Training surgery residents in underwater colonoscopies is more effective than training them in air-insufflation colonoscopies
449 downloads medRxiv surgery

Dinesh Vyas, Josiah Chang, Megha Goyal, Nashwan Obad, Prakash Ramdass, Soujanya Sodavarapu

Background: Colonoscopy screenings are the most valuable tool in preventing colorectal mortalities. The traditional technique uses air-insufflation, but water-infusion is a newer colonoscopy technique which is rapidly becoming standard of care, as it may decrease patient discomfort and the need for analgesics and anesthetics. Research is still ongoing as to the comparability of detection rates between the two techniques. The purpose of this study was to determine if training residents in underwater colonoscopies is more effective than training them in traditional air-insufflation colonoscopies. Methods: This study was a retrospective, single-institution study that compared the patient-related and procedure-related variables of 183 colonoscopies performed by two cohorts of physicians. In the first cohort, the gastroenterologist with a resident trainee performed an air colonoscopy. In the second, the gastroenterologist and resident trainee performed an underwater colonoscopy. Results: For patient-related variables, there was no significant difference in age, previous abdominal surgeries, or bowel preparation. There were more females in the underwater group, which is significant as females tend to be harder to scope due to the increased tortuosity of their colon. For procedural outcomes, there was no significant difference in adenoma detection rate, cecal intubation rate, or procedural complications (hypotension, bradycardia). On average, the water colonoscopies required less midazolam and fentanyl, although they did have a longer procedural time. Conclusions: Overall, these findings suggest that training residents in underwater colonoscopies may increase patient comfort and decrease complications with comparable success rates.

28: Real-world, Prospective, and Multicenter Validation of a microRNA-based Thyroid Molecular Classifier
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Posted 28 Oct 2020

Real-world, Prospective, and Multicenter Validation of a microRNA-based Thyroid Molecular Classifier
448 downloads medRxiv surgery

Marcos Tadeu dos Santos, Bruna Moretto Rodrigues, Satye Shizukuda, David Livingstone Alves Figueiredo, Giulianno Molina de Melo, Rubens Adão da Silva, Claudio Fainstein, Gerson Felisbino dos Reis, Rossana Corbo, Helton Estrela Ramos, Fernanda Vaisman, Mário Vaisman

BackgroundThe diagnosis of cancer in thyroid nodules with indeterminate cytology (Bethesda III/IV) is challenging as fine-needle aspiration (FNA), the gold standard method, has limitations, and these cases usually require diagnostic surgery. As approximately 77% of these nodules are not malignant, a diagnostic test accurately identifying benign thyroid nodules can reduce surgery rates. We have previously reported the development and validation of a microRNA-based thyroid molecular classifier for precision endocrinology (mir-THYpe) with high sensitivity and specificity, which could be performed directly from readily available cytological smear slides without the need for a new dedicated FNA. We sought to evaluate whether the use of this test in real-world clinical routine can reduce the rates of surgeries for Bethesda III/IV thyroid nodules and analyze the test performance. MethodsWe designed a real-world, prospective, multicenter cohort study. Molecular tests were performed in a real-world clinical routine with samples (FNA smear slides) prepared at 128 cytopathology laboratories. Patients were followed-up from March 2018 until surgery or until March 2020 (for those patients not recommended for surgery). The final diagnosis of thyroid tissue samples was retrieved from postsurgical anatomopathological reports. ResultsAfter applying the exclusion criteria, 435 patients (440 nodules) classified as Bethesda III/IV were followed-up. The rate of avoided surgeries was 52.5% for all surgeries and 74.6% for "potentially unnecessary" surgeries. After the statistical treatment of non-resected test-negative samples, the test achieved 89.3% sensitivity (95% CI 82-94.3), 81.65% specificity (95% CI 76.6-86), 66.2% positive predictive value (95% CI 60.3-71.7), and 95% negative predictive value (95% CI 91.7-97) at 28.7% (95% CI 24.3-33.5) cancer prevalence. The test influenced 92.3% of clinical decisions. ConclusionsThe reported data demonstrate that the use of the microRNA-based classifier in the real-world can reduce the rate of thyroid surgery with robust performance and significantly influence clinical decision-making.

29: IMPACT OF THE CORONAVIRUS DISEASE 2019 PANDEMIC ON SURGICAL VOLUME IN JAPAN: A COHORT STUDY USING ADMINISTRATIVE DATA
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Posted 20 Nov 2020

IMPACT OF THE CORONAVIRUS DISEASE 2019 PANDEMIC ON SURGICAL VOLUME IN JAPAN: A COHORT STUDY USING ADMINISTRATIVE DATA
448 downloads medRxiv surgery

Takuya Okuno, Daisuke Takada, Shin Jung-ho, Tetsuji Morishita, Hisashi Itoshima, Susumu Kunisawa, Yuichi Imanaka

BackgroundInternationally, the Coronavirus Disease (COVID-19) pandemic has caused unprecedented challenges for surgical staff to minimise the exposure to COVID-19 or save medical resources without harmful outcomes for patients, in accordance with the statement of each surgical society. However, no research has empirically validated declines in Japanese surgical volume or compared decrease rates of surgeries during the COVID-19 pandemic. Material and MethodsWe extracted 672,772 available cases of patients aged > 15 years who were discharged between July 1, 2018, and June 30, 2020. After categorisation of surgery, we calculated descriptive statistics to compare the year-over-year trend and conducted interrupted time series analysis to validate the decline. ResultsThe year-over-year trend of all eight surgical categories decreased from April 2020 and reached a minimum in May 2020 (May: abdominal, 68.4%; thoracic, 85.8%; genitourinary, 78.6%; cardiovascular, 90.8%; neurosurgical, 69.1%; orthopaedic, 62.4%; ophthalmologic, 52.0%; ear/nose/throat, 27.3%). Interrupted time series analysis showed no significant trends in oncological and critical benign surgeries. ConclusionWe demonstrated and validated a trend of reduction in surgical volume in Japan using administrative data applying interrupted time series analyses. Low priority surgeries, as categorised by the statement of each society, showed obvious and statistically significant declines in case volume during the COVID-19 pandemic.

30: Laparoscopic vs open gastrectomy. An updated metaanalysis of randomised control trials for short term outcomes and updated metaanalysis for long term over all and disease free survival outcomes.
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Posted 15 Apr 2020

Laparoscopic vs open gastrectomy. An updated metaanalysis of randomised control trials for short term outcomes and updated metaanalysis for long term over all and disease free survival outcomes.
445 downloads medRxiv surgery

BHAVIN VASAVADA, hardik patel

Introduction: Aim of this metaanalysis was to compare short term outcomes of laparoscopic and open gastrectomy for gastric cancer. Material and methods: EMBASE, MEDLINE, PubMed and the Cochrane Database were searched for randomised control trials comparing outcomes in patients undergoing laparoscopic gastrectomies with those patients undergoing open gastrectomies. The primary outcome was 30 day morbidity and mortality. Secondary outcomes studied included length of stay, blood loss, d2gastrectomies, lymphnode retrieval, operative time, distal gastrectomy, wound complications and intraabdominal complications Systemic review and Metaanalysis were done according to MOOSE and PRISMA guidelines. Results: Morbidity was significantly low in laparoscopic group( P=0.004).There was no significant difference between mortality between the two groups. (P=0.989). There less wound complications in laparoscpic group, no difference intra-abdominal complications in both the groups. Operative time was significantly higher in laparoscopic group.( P< 0.001) wmd 56.904. Hospital stay was similar in laparoscopic group. (P=0.305) wmd -0.533 days. Blood loss was significantly lesser in laparoscopic group.(p <0.001). Laparoscopic group patients had less number of lymph node retrieval compared to laparoscopic group.(p< 0.001). Laparoscopic group also contained similar advanced staged gastric cancer than open gastrectomies. Conclusions: Laparoscopic gastrectomies were associated with better short term outcomes.

31: Data Visualization for Surgical Informed Consent to Communicate Personalized Risks and Patient Preferences
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Posted 27 Mar 2020

Data Visualization for Surgical Informed Consent to Communicate Personalized Risks and Patient Preferences
432 downloads medRxiv surgery

Undina Gisladottir, Drashko Nakikj, Rashi Jhunjhunwala, Gabriel Brat, Nils Gehlenborg

STRUCTURED ABSTRACTO_ST_ABSObjectiveC_ST_ABSIdentify key elements of an effective visualization method for communicating personalized surgical risks to patients. BackgroundCurrently, there is no consensus on which risks should be communicated during the informed consent process and how. Furthermore, patient preferences are often not considered during the consent process. These inefficiencies can lead to non-beneficial outcomes and raise the potential for legal implications. To address the limitations of the informed consent process, we propose a visual consent tool (VCT) that incorporates patient preferences and communicates personalized risks to patients using data visualization. MethodsTo understand how patients perceive risk visualizations and their role in the informed consent discussion, we gathered feedback on visualizations by conducting semi-structured interviews during postoperative visits. Thematic analysis was performed to identify major themes. Iterative evaluation and consolidation of the major themes were performed with domain experts. ResultsA total of 20 patients were interviewed for this study with a median age of 59 (sd = 14). The thematic analysis revealed factors that influence the perception of risk, of risk visualizations, and the usefulness of the proposed VCT. We found that patients preferred VCT over the current methods and had different preferences for risk visualization. Further, our findings suggest that surgical concerns of patients were not in line with existing risk calculators. ConclusionWe were able to identify key elements that influence effective risk communication in the perioperative setting. We found that patient preference is variable and should influence choices for risk presentation and visualization.

32: Direct Molecular Analysis of In Vivo and Freshly Excised Tissues in Human Surgeries with the MasSpec Pen Technology
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Posted 16 Dec 2020

Direct Molecular Analysis of In Vivo and Freshly Excised Tissues in Human Surgeries with the MasSpec Pen Technology
429 downloads medRxiv surgery

Jialing Zhang, Marta Sans, Rachel J. DeHoog, Kyana Y. Garza, Mary E. King, Clara L. Feider, Alena Bensussan, Michael F. Keating, John Q. Lin, Sydney Povilaitis, Nitesh Katta, Thomas E. Milner, Wendong Yu, Chandandeep Nagi, Sadhna Dhingra, Christopher Pirko, Kirtan A. Brahmbhatt, George Van Buren, Stacey Carter, William E. Fisher, Alastair Thompson, Raymon H. Grogan, James Suliburk, Livia S Eberlin

Intraoperative tissue analysis is critical to guide surgical procedures and improve patient outcomes. Here, we describe the clinical translation and intraoperative use of the MasSpec Pen technology for direct molecular analysis of in vivo and freshly excised tissues in the operating room. In this study, the MasSpec Pen was used by surgeons and surgical staff during 100 surgeries over a 12-month period, allowing rapid detection of rich mass spectral profiles from 715 in vivo and ex vivo analyses performed on thyroid, parathyroid, lymph node, breast, pancreatic, and bile duct tissues during parathyroidectomies, thyroidectomies, breast, and pancreatic neoplasia surgeries. The MasSpec Pen enabled gentle extraction and sensitive detection of various molecular species including small metabolites and lipids using a droplet of sterile water without causing apparent tissue damage. Notably, effective molecular analysis was achieved while no limitations to sequential histologic tissue analysis were identified and no device-related complications were reported for any of the patients. Collectively, this study shows that the MasSpec Pen system can be successfully incorporated into the operating room, allowing direct detection of rich molecular profiles from tissues with a seconds-long turnaround time that could be inform surgical and clinical decisions without disrupting tissue analysis workflows.

33: Pediatric surgical services in Bangladesh during the COVID 19 pandemic: How they are affected and how to overcome the backlog, keeping healthcare professionals safe.
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Posted 21 Aug 2020

Pediatric surgical services in Bangladesh during the COVID 19 pandemic: How they are affected and how to overcome the backlog, keeping healthcare professionals safe.
427 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Md Samiul Hasan

Background: Severe Acute Respiratory syndrome coronavirus 2 (SARS-CoV-2), which originated in Wuhan, China, has turned into a pandemic. All countries have implemented multiple strategies to try mitigating the losses caused by this virus. To stop the rapid spread of the disease and in compliance with the World Health Organizations social distancing policy, the government of Bangladesh has implemented a number of strategies, one of which is to limit the spread of the virus in hospitals by postponing elective procedures and providing only emergency services in the hospitals. The objective of this survey was to assess the current status of pediatric surgical procedures in different hospitals in Bangladesh and assess the effects of the current restrictions along with their implications in the long run. Materials and Methods: A survey was performed among doctors from public and private hospitals in Bangladesh to evaluate the status on pediatric surgery. Results: The results clearly revealed the lack of a significant reduction in doctors exposure to SARS-CoV-2 by postponing elective procedures. Conclusion: Keeping in mind the socioeconomic and health care conditions of the country, the author recommend resuming elective surgical procedures. Keywords: COVID 19, Pediatric surgery, Surgery during pandemic, Pediatric surgery in Bangladesh, COVID 19 and pediatric surgery.

34: The impact of the Covid-19 pandemic on emergency and elective hip surgeries in Norway
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Posted 11 Sep 2020

The impact of the Covid-19 pandemic on emergency and elective hip surgeries in Norway
418 downloads medRxiv surgery

Karin Magnusson, Jon Helgeland, Mari Grosland, Kjetil Elias Telle

Objective: To assess the effects of Covid-19 pandemic lockdown restrictions on the number of emergency and elective hip joint surgeries, and explore whether these procedures are more/less affected by lockdown restrictions than other hospital care. Methods: In 1.344.355 persons aged [&ge;]35 years in the Norwegian emergency preparedness (BEREDT C19) register, we studied the daily number of persons having 1) emergency surgeries due to hip fractures, and 2) electively planned surgeries due to hip osteoarthritis before and after Covid-19 lockdown restrictions were implemented nationally on March 13th 2020, for different age and sex groups. Incidence Rate Ratios [IRR] reflect the after-lockdown number of surgeries divided by the before-lockdown number of surgeries. Results: After-lockdown elective hip surgeries were one third the number of before-lockdown (IRR ~0.3), which is a greater drop than the drop seen in all-cause elective hospital care (IRR ~0.6) (no age/sex differences). Men aged 35-69 had half the number of emergency hip fracture surgeries (IRR ~0.6), whereas women aged [&ge;]70 had the same number of emergency hip fracture surgeries after lockdown (IRR ~1). Only women aged 35-69 and men aged [&ge;]70 had emergency hip fracture surgery rates after lockdown comparable to what may be expected based on analyses of all-cause acute care (IRR ~0.80) Conclusion: Important to note for future pandemics management is that lockdown restrictions may impact more on scheduled joint surgery than other scheduled hospital care. Lockdown may also impact on the number of emergency joint surgeries for men aged [&ge;]35 but not for women aged [&ge;]70.

35: Predictive value of Altmetric Score on prospective citation and bibliometric impact: rise of a new argot
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Posted 20 May 2020

Predictive value of Altmetric Score on prospective citation and bibliometric impact: rise of a new argot
397 downloads medRxiv surgery

David BT Robinson, Arfon G Powell, Jennifer Waterman, Luke G Hopkins, Osian P James, Richard J Egan, Wyn G Lewis

Background Bibliometric and Altmetric analyses provide important but alternative perspectives regarding research article impact. This study aimed to establish whether Altmetric Score (AS) was associated with citation rate, independent of bibliometrics. Method Citations for a previously reported cohort of 100 most cited articles associated with the keyword Surgery (2018, Powell et al), were collected and a three year interval Citation Gain (iCG) evaluated. Previous citation count, Citation Rate Index (CRI), AS, five year Impact Factor, and Oxford Centre for Evidence Based Medicine (OCEBM) levels were used to classify citation rate prospect. Results During follow-up, the median iCG was 161 (IQR 83 to 281), with 73 and 62 articles receiving an increase in CRI and AS, respectively. Median CRI and AS increase were 2.8 (-0.1 to 7.7) and 3 (0 to 4), respectively. Receiver Operator Characteristic (ROC) analysis revealed that CRI (AUC 0.86 (95% CI 0.79 to 0.93), p<0.001) and AS (Area Under Curve (AUC) 0.65 (95% CI 0.55 to 0.76), p=0.008) were associated with higher iCG. AS critical threshold greater than or equal to 2.0 was associated with better iCG when dichotomised at iCG median (OR=4.94, 95% CI 1.99 to 12.26, p=0.001) and iCG Upper Quartile (UQ, OR=4.13, 95% CI 1.60 to 10.66, p=0.003). Multivariable analysis identified that only CRI was independently associated with iCG when dichotomised at the median (OR 18.22, 95% CI 6.70 to 49.55, p<0.001) and UQ (OR 19.30, 95% CI 4.23 to 88.15, p<0.001). Conclusion Citation Rate Indices and Altmetric Scores are important predictors of interval Citation Gain, and better at predicting future citations than the historical and established Impact Factor and OCEBM quality of evidence descriptors.

36: Surgery & COVID-19: A rapid scoping review of the impact of COVID-19 on surgical services during public health emergencies
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Posted 04 Dec 2020

Surgery & COVID-19: A rapid scoping review of the impact of COVID-19 on surgical services during public health emergencies
392 downloads medRxiv surgery

Connor O'Rielly, Joshua Ng Kamstra, Ania Kania-Richmond, Joseph C Dort, Jonathan White, Jill Robert, Mary Brindle, Khara M Sauro

Background: Healthcare systems globally have been challenged by the COVID-19 pandemic, necessitating the reorganization of surgical services to free capacity within healthcare systems. Objectives: To understand how surgical services have been reorganized during and following public health emergencies, and the consequences of these changes for patients, healthcare providers and healthcare systems. Methods: This rapid scoping review searched academic databases and grey literature sources to identify studies examining surgical service delivery during public health emergencies including COVID-19, and the impact on patients, providers and healthcare systems. Recommendations and guidelines were excluded. Screening was completed in partial (title, abstract) or complete (full text) duplicate following pilot reviews of 50 articles to ensure reliable application of eligibility criteria. Results: One hundred and thirty-two studies were included in this review; 111 described reorganization of surgical services, 55 described the consequences of reorganizing surgical services and six reported actions taken to rebuild surgical capacity in public health emergencies. Reorganizations of surgical services were grouped under six domains: case selection/triage, PPE regulations and practice, workforce composition and deployment, outpatient and inpatient patient care, resident and fellow education, and the hospital or clinical environment. Service reorganizations led to large reductions in non-urgent surgical volumes, increases in surgical wait times, and impacted medical training (i.e., reduced case involvement) and patient outcomes (e.g., increases in pain). Strategies for rebuilding surgical capacity were scarce, but focused on the availability of staff, PPE, and patient readiness for surgery as key factors to consider before resuming services. Conclusions: Reorganization of surgical services in response to public health emergencies appears to be context-dependent and has far-reaching consequences that must be better understood in order to optimize future health system responses to public health emergencies.

37: Research transparency promotion by surgical journals publishing randomised controlled trials: a survey
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Posted 22 Jul 2019

Research transparency promotion by surgical journals publishing randomised controlled trials: a survey
387 downloads medRxiv surgery

N. Lombard, A. Gasmi, L. Sulpice, K. Boudjema, Florian Naudet, D. Bergeat

ObjectiveTo describe the surgical journal position statement on data-sharing policies (primary objective) and to describe the other features of their research transparency promotion. MethodsOnly "SURGICAL" journals with an impact factor superior to 2 (Web of Science) were eligible for the study. They were not included if there were no explicit instructions for clinical trial publication in the instructions for authors and if there were no RCT published between January 2016 and January 2019. The primary outcome was the existence of a data-sharing policy in the instructions for authors. Details on research transparency promotion were also collected, namely the existence of a "prospective registration of clinical trials requirement" policy; a "COIs" disclosure requirement and a specific reference to reporting guidelines such as CONSORT for RCT. ResultsAmong the 87 surgical journals eligible, 82 (94%) were included in the analysis: 67 (77%) had explicit instructions for RCT and of the remaining, 15 (17.2%) had published at least one RCT between 2016-2019. The median impact factor was 2.98 [IQR=2.48-3.77] and in 2016 and 2017, the journals published a median of 11.5 RCT [IQR=5-20.75]. Data-sharing statement instructions (primary outcome) were ICMJE-compliant in four cases (4.88%), weaker in 45.12% (n=37) and inexistent in 50% (n=41) of the journals. As for data-sharing statements, no association was found between journal characteristics and the existence of data-sharing policies (ICMJE-compliant or weaker). A "prospective registration of clinical trials requirement" was associated with ICMJE allusion or affiliation and higher impact factors. Journals with specific RCT instructions in their OIA and journals referenced on the ICMJE website more frequently mandated the use of CONSORT guidelines. ConclusionResearch transparency promotion is still limited in surgical journals. Uniformization of journal requirements vis-a-vis ICMJE guidelines could be a first step forward for research transparency promotion in surgery.

38: Spinal Anesthesia is Safe and Cost-effective for Laparoscopic Appendectomy in Children: A Case-Control Study
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Posted 21 Oct 2020

Spinal Anesthesia is Safe and Cost-effective for Laparoscopic Appendectomy in Children: A Case-Control Study
368 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Alak Nandy, Md Samiul Hasan

STRUCTURED ABSTRACTO_ST_ABSBackgroundC_ST_ABSOwing to the widespread use of general anesthesia, administration of spinal anesthesia in pediatrics is not widely practiced. Yet there is ample positive evidence demonstrating its safety, effectiveness and success. ObjectiveThe objective of this study is to demonstrate that laparoscopic appendectomies are successful under spinal anesthesia and elicit clear advantages over general anesthesia. MethodsThis was a retrospective analysis of 77 pediatric (5-8 year old) laparoscopic appendectomies that took place in a Hospital, Chittagong, Bangladesh in 2019. Approximately half of the patients underwent spinal anesthesia while the other half underwent general anesthesia. Variables such as surgery and operation theatre times, pain score, incidence of post-surgery vomiting, analgesic usage, discharge times and hospital costs were recorded. Statistical analysis was used to analyze the data as a function of form of anesthesia. ResultsThe probability of vomiting when using spinal compared to general anesthesia was much lower within the first 5 hours (P < .001) and after 6 hours (P = .008) of operation. Highly significant difference (P < .001) was observed in the total costs of the procedures. A significantly higher likelihood of patients being discharged the same day of the procedure was noted if spinal anesthesia was used (P = .008). ConclusionsSpinal anesthesia is superior to general anesthesia for pediatric laparoscopic appendectomies. Patient comfort is improved through a significant decrease in vomiting. This enables more rapid hospital discharges and a significant cost saving, without compromising the outcome of the procedure. MINI-ABSTRACTSpinal anesthesia is seldom used for laparoscopy in children. This retrospective case-controlled study compared spinal anesthesia with general anesthesia in children between 5 and 8 years of age. Spinal anesthesia proved to be safer and cost-effective for laparoscopy in children.

39: Management of Acute Appendicitis in Children: Takeaway from Coronavirus Disease-2019, a Perspective of Pediatric Surgeons from South Asia
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Posted 27 Oct 2020

Management of Acute Appendicitis in Children: Takeaway from Coronavirus Disease-2019, a Perspective of Pediatric Surgeons from South Asia
367 downloads medRxiv surgery

Md Jafrul Hannan, Kohinoor Parveen, Md Mozammel Hoque, Tanvir Kabir Chowdhury, Md Samiul Hasan, Alak Nandy

BackgroundNon-operative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and potentially influenced by the preferences of the physician. Owing to the effects of the COVID pandemic on healthcare, practice of NOT has generally increased by necessity and may, in a post-COVID world, change surgeons perceptions of NOT. ObjectiveThe objective was to determine if the practice of NOT has increased in usage in South Asia and whether these levels of practice would be sustained after the pandemic subside. MethodsA survey was addressed to pediatric surgeons regarding their position, institute, country, number of appendicitis cases managed and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). It also directly posed the question as to whether they would continue with the COVID imposed level of NOT after the effect of the pandemic diminishes. ResultsA total of 134 responses were collected. A significant increase in the practice of NOT was observed for the entire cohort, though no effect was observed when grouped by country or institute. When grouped by position, seniors increased the practice of NOT the most, while juniors reported the least change. The data suggests that only Professors would be inclined to maintaining the COVID level of NOT practice after the pandemic. ConclusionsIncreased practice of NOT during the COVID pandemic was observed in South Asia, particularly by senior surgeons. Only Professors appear inclined to consider maintaining this increased level of practice in the post-COVID world.

40: Portuguese Inguinal Hernia Cohort (PINE) study
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Posted 22 Dec 2020

Portuguese Inguinal Hernia Cohort (PINE) study
353 downloads medRxiv surgery

PT Surg – Portuguese Surgical Research Collaborative, J Simões, AA João, JM Azevedo, M Peyroteo, M Cunha, B Vieira, N Gonçalves, J Costa, AS Soares, JS Pimenta, M Romano, AM Cinza, I Miguel, AR Martins, G Fialho, M Reia, FC Borges, CF Monteiro, AC Soares, P Sousa, S Frade, L Matos, JM Carvas, SF Martins, X Sousa, C. Rodrigues, JR Carvalho, IC Gil, L Castro, N Rombo, AC Quintela, HM Ribeiro, R Parreira, P Santos, F Caires, A Torre, S.C. Rodrigues, AH Guimarães, MF Carvalho, MA Pimentel, DC Santos, CF Ramos, C Cunha, C. Azevedo

PurposeRecent comprehensive guidelines have been published on the management of inguinal hernia. Contrary to other European countries, no Portuguese hernia registry exists. This represents an opportunity to assess outcomes of hernia surgery in the Portuguese population. The primary aim is to define the prevalence of chronic pain after elective inguinal hernia repair. The secondary aims are to identify risk factors for chronic pain after elective inguinal hernia repair, to characterise the management of elective inguinal hernia in public Portuguese hospitals. MethodsProspective national cohort study of patients submitted to elective inguinal hernia repair. The primary outcome is the prevalence of chronic postoperative inguinal pain, according to the EuraHS QoL questionnaire at 3 months postoperatively. The study will be delivered in all Portuguese regions through a collaborative research network. Four 2-week inclusion periods will be open for recruitment. A site-specific questionnaire will capture procedure volume and logistical facilities for hernia surgery. ConclusionThis protocol describes the methodology of a prospective cohort study on the elective management of inguinal hernia. It discusses key challenges and describes how the results will impact future investigation. The study will be conducted across a nationwide collaborative research network, with prospective quality assurance and data validation strategies. It will provide the basis for a more accurate prediction of chronic postoperative inguinal pain and the research on adequate patient selection strategies for surgery and therapeutic strategies for postoperative pain.

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