Factors Affecting Surgical Decision-making-A Qualitative Study

AI Versus MD: Evaluating the surgical decision-making accuracy of ChatGPT-4

BACKGROUND

ChatGPT-4 is a large language model with possible applications to surgery education The aim of this study was to investigate the accuracy of ChatGPT-4's surgical decision-making compared with general surgery residents and attending surgeons.

METHODS

Five clinical scenarios were created from actual patient data based on common general surgery diagnoses. Scripts were developed to sequentially provide clinical information and ask decision-making questions. Responses to the prompts were scored based on a standardized rubric for a total of 50 points. Each clinical scenario was run through Chat GPT-4 and sent electronically to all general surgery residents and attendings at a single institution. Scores were compared using Wilcoxon rank sum tests.

RESULTS

On average, ChatGPT-4 scored 39.6 points (79.2%, standard deviation ± 0.89 points). A total of five junior residents, 12 senior residents, and five attendings completed the clinical scenarios (resident response rate = 15.9%; attending response rate = 13.8%). On average, the junior residents scored a total of 33.4 (66.8%, standard deviation ± 3.29), senior residents 38.0 (76.0%, standard deviation ± 4.75), and attendings 38.8 (77.6%, standard deviation ± 5.45). ChatGPT-4 scored significantly better than junior residents (P = .009) but was not significantly different from senior residents or attendings. ChatGPT-4 was significantly better than junior residents at identifying the correct operation to perform (P = .0182) and recommending additional workup for postoperative complications (P = .012).

CONCLUSION

ChatGPT-4 performed superior to junior residents and equivalent to senior residents and attendings when faced with surgical patient scenarios. Large language models, such as ChatGPT, may have the potential to be an educational resource for junior residents to develop surgical decision-making skills.

Factors influencing the decision-making process in breast reconstruction from the perspective of reconstructive surgeons: A qualitative study involving Korean plastic surgeons

BACKGROUND

Little research has been conducted on factors influencing the decision-making process for immediate breast reconstruction (IBR) options from the perspective of reconstructive surgeons, despite its significant impact on doctor-patient communication and shared decision-making. This study aims to explore the multiple factors and the mechanisms by which they interact using a qualitative methodology. We also address potential barriers to shared decision-making in IBR.

METHODS

Semistructured interviews were conducted with a purposive sample of reconstructive surgeons. Thematic analysis was used to identify key influences on IBR decision-making process from the perspective of reconstructive surgeons.

RESULTS

Four major themes were identified: 1. Patient clinical scenarios; 2. Nonclinical practice environments; 3. Reconstructive surgeon preferences; and 4. Patient consultation. Reconstructive surgeons demonstrated diverse approaches to patient clinical scenarios. High-volume centers were significantly influenced by nonclinical factors such as scheduling and operating room allocation systems. Reconstructive surgeons often had strong personal preferences for specific IBR options, shaped by their expertise, experience, and clinical environment. Based on the preliminary decision, surgeons provided information with varying degrees of neutrality. Patients varied in their knowledge and participation, resulting in variation in the final decision authority among surgeons.

CONCLUSIONS

This study highlights the need to address nonclinical environmental constraints to improve shared decision-making process in IBR. Surgeons should recognize power imbalances in the doctor-patient relationship and be aware of their biases.

Incidence and predictors of postoperative complications in Sub-Saharan Africa: a systematic review and meta-analysis

Background

Postoperative complications remain a significant challenge, especially in settings where healthcare access and infrastructure disparities exacerbate. This systematic review and meta-analysis aimed to determine the pooled incidence and risk factors of postoperative complications among patients undergoing essential surgery in Sub-Saharan Africa (SSA).

Method

PubMed/MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar were searched from January 2010 to November 2022 for completed studies reporting the incidence and risk factors associated with postoperative complications among patients undergoing essential surgery in SSA. Severity of postoperative complications was ranked based on the Clavien-Dindo classification system, while risk factors were classified into three groups based on the Donabedian structure-process-outcome quality evaluation framework. Studies quality was appraised using the JBI Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI), and data were analyzed using Comprehensive Meta-Analysis (CMA) software. The study protocol adhered to the PRISMA guidelines and was registered in PROSPERO (CRD42023414342).

Results

The meta-analysis included 19 studies (10 cohort and 9 cross-sectional) comprising a total of 24,136 patients. The pooled incidence of postoperative complications in SSA was 20.2% (95% CI: 18.7%-21.8%), with a substantial heterogeneity of incidence observed. The incidence varied from 14.6% to 27.5% based on the Clavien-Dindo classification. The random-effects model indicated significant heterogeneity among the studies (Q = 54.202, I = 66.791%, p < 0.001). Contributing factors to postoperative complications were: structure-related factors, which included the availability and accessibility of resources, as well as the quality of both the surgical facility and the hospital.; process-related factors, which encompassed surgical skills, adherence to protocols, evidence-based practices, and the quality of postoperative care; and patient outcome-related factors such as age, comorbidities, alcohol use, and overall patient health status.

Conclusion

The meta-analysis reveals a high frequency of postoperative complications in SSA, with noticeable discrepancies among the studies. The analysis highlights a range of factors, encompassing structural, procedural, and patient outcome-related aspects, that contribute to these complications. The findings underscore the necessity for targeted interventions aimed at reducing complications and improving the overall quality of surgical care in the region.

Systematic Reviews Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier (CRD42023414342).

Review and analysis of history and utilization of pneumatic retinopexy after pneumatic retinopexy versus vitrectomy for the management of primary rhegmatogenous retinal detachment outcomes randomized trial (PIVOT)

PURPOSE OF REVIEW

We describe the history and series results of pneumatic retinopexy (PnR)and provide an analysis of PnR utilization after publication of results of pneumatic retinopexy versus vitrectomy for the management of primary rhegmatogenous retinal detachment outcomes randomized trial (PIVOT).

RECENT FINDINGS

No significant trends were found for average number of services ( P  = 0.153) of PnR after the publication of PIVOT results.

SUMMARY

PnR is a rhegmatogenous retinal detachment (RRD) repair technique that was first described in the early 1900 s and has evolved over time to become a modern-day, minimally invasive, underutilized treatment option. Other repair techniques for RRD include scleral buckling and pars plana vitrectomy (PPV), which has been compared to the use of PnR in PIVOT. Results of PIVOT concluded that PnR offered superior visual acuity and noninferiority. PnR is underutilized in the United States even after publication of results of PIVOT deemed it a noninferior treatment. Lack of a significant increase in national utilization of PnR could be associated with multifactorial clinician, systems, and financial reasons in the real-world setting.

Association of Radiographic Soft Tissue Thickness With Revision Total Ankle Arthroplasty Following Primary Total Ankle Arthroplasty: A Minimum of 5-year Follow-up

Background

The incidence of primary total ankle arthroplasty (TAA) is rising, with a corresponding increase in revision surgeries. Despite this, research on risk factors for revision TAA following primary TAA remains limited. Radiographic soft tissue thickness has been explored as a potential predictor for outcomes in hip, knee, and shoulder arthroplasty, but its role in TAA has not been assessed. This study aimed to assess the predictive value of radiographic soft tissue thickness for identifying patients at risk of requiring revision surgery following primary TAA.

Methods

A retrospective study was conducted on 323 patients who underwent primary TAA between 2003 and 2019. Radiographic measurements of soft tissue thickness were obtained from preoperative radiographs. Two novel radiographic measures of soft tissue thickness were developed and assessed (tibial tissue thickness and talus tissue thickness). Clinical variables including age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, diabetes, smoking status, primary diagnosis, and implant type were recorded. Logistic regression analysis was used to assess the predictive value of soft tissue thickness and BMI for revision TAA.

Results

The rate of revision surgery was 4.3% (14 of 323 patients). Patients requiring revision had significantly greater tibial tissue (3.54 vs 2.48 cm; P = .02) and talus tissue (2.79 vs 2.42 cm; P = .02) thickness compared with those not requiring revision. Both the tibial tissue thickness (odds ratio 1.16 [1.12-1.20]; P < .01) and the talus tissue thickness (odds ratio: 1.10 [1.05-1.15]; P < .01) measurements were significant predictors of revision TAA in multivariable logistic regression models. However, BMI was not a significant predictor of revision TAA. The two metrics demonstrated excellent interrater reliability.

Conclusion

Greater soft tissue thickness was a better predictor of revision TAA compared with BMI. These findings suggest that radiographic soft tissue thickness may be a valuable tool for assessing the risk of the need for revision TAA following primary TAA. Further research is needed to validate and explore the potential impact on clinical practice.

Level of Evidence

Level III, comparative study.

Variations in surgical practice and short-term outcomes for degenerative lumbar scoliosis and spondylolisthesis: do surgeon training and experience matter?

For diverse procedures, sizable geographic variation exists in rates and outcomes of surgery, including for degenerative lumbar spine conditions. Little is known about how surgeon training and experience are associated with surgeon-level variations in spine surgery practice and short-term outcomes. This retrospective observational analysis characterized variations in surgical operations for degenerative lumbar scoliosis or spondylolisthesis, two common age-related conditions. The study setting was two large spine surgery centers in one region during 2017-19. Using data (International Classification of Diseases-10th edition and current procedural terminology codes) extracted from electronic health record systems, we characterized surgeon-level variations in practice (use of instrumented fusion - a more extensive procedure that involves device-related risks) and short-term postoperative outcomes (major in-hospital complications and readmissions). Next, we tested for associations between surgeon training (specialty and spine fellowship) and experience (career stage and operative volume) and use of instrumented fusion as well as outcomes. Eighty-nine surgeons performed 2481 eligible operations. For the study diagnoses, spine surgeons exhibited substantial variation in operative volume, use of instrumented fusion, and postoperative outcomes. Among surgeons above the median operative volume, use of instrumented fusion ranged from 0% to >90% for scoliosis and 9% to 100% for spondylolisthesis, while rates of major in-hospital complications ranged from 0% to 25% for scoliosis and from 0% to 14% for spondylolisthesis. For scoliosis, orthopedic surgeons were more likely than neurosurgeons to perform instrumented fusion for scoliosis [49% vs. 33%, odds ratio (OR) = 2.3, 95% confidence interval (95% CI) 1.3-4.2, P-value = .006] as were fellowship-trained surgeons (49% vs. 25%, OR = 3.0, 95% CI 1.6-5.8; P = .001). Fellowship-trained surgeons had lower readmission rates. Surgeons with higher operative volumes used instrumented fusion more often (OR = 1.1, 95% CI 1.0-1.2, P < .05 for both diagnoses) and had lower rates of major in-hospital complications (OR = 0.91, 95% CI 0.85-0.97; P = .006). Surgical practice can vary greatly for degenerative spine conditions, even within the same region and among colleagues at the same institution. Surgical specialty and subspecialty, in addition to recent operative volume, can be linked to variations in spine surgeons' practice patterns and outcomes. These findings reinforce the notion that residency and fellowship training may contribute to variation and present important opportunities to optimize surgical practice over the course of surgeons' careers. Future efforts to reduce unexplained variation in surgical practice could test interventions focused on graduate medical education. Graphical Abstract.

Substantial Variation in Decision Making to Perform Subacromial Decompression Surgery for Subacromial Pain Syndrome Between Orthopaedic Shoulder Surgeons for Identical Clinical Scenarios: A Case-Vignette Study

Purpose

To provide further insight into the variation in decision making to perform subacromial decompression (SAD) surgery in patients with subacromial pain syndrome (SAPS) and its influencing factors.

Methods

Between November 2021 and February 2022, we invited 202 Dutch Shoulder and Elbow Society members to participate in a cross-sectional Web-based survey including 4 clinical scenarios of SAPS patients. Scenarios varied in patient characteristics, clinical presentation, and other contextual factors. For each scenario, respondents were asked (1) to indicate whether they would perform SAD surgery, (2) to indicate the probability of benefit of SAD surgery (i.e., pain reduction), (3) to indicate the probability of harm (i.e., complications), and (4) to rank the 5 most important factors influencing their treatment decision.

Results

A total of 78 respondents (39%) participated. The percentage of respondents who would perform SAD surgery ranged from 4% to 25% among scenarios. The median probability of perceived benefit ranged between 70% and 79% across scenarios for respondents indicating to perform surgery compared with 15% to 29% for those indicating not to perform surgery. The difference in the median probability of perceived harm ranged from 3% to 9% for those indicating to perform surgery compared with 8% to 13% for those indicating not to perform surgery. Surgeons who would perform surgery mainly reported patient-related factors (e.g., complaint duration and response to physical therapy) as the most important factors to perform SAD surgery, whereas surgeons who would not perform surgery mainly reported guideline-related factors.

Conclusions

Overall, Dutch orthopaedic shoulder surgeons are reluctant to perform SAD surgery in SAPS patients. There is substantial variation among orthopaedic surgeons regarding decisions to perform SAD surgery for SAPS even when evaluating identical scenarios, where particularly the perceived benefit of surgery differed between those who would perform surgery and those who would not. Surgeons who would not perform SAD surgery mainly referred to guideline-related factors as influential factors for their decision, whereas those who would perform SAD surgery considered patient-related factors more important.

Clinical Relevance

There is substantial variation in decision making to perform SAD surgery for SAPS between individual orthopaedic surgeons for identical case scenarios.

Surgeon Preference for Prophylactic Contralateral Fixation in Slipped Capital Femoral Epiphysis (SCFE) Patients: A Nationwide POSNA Survey Study

BACKGROUND

It is estimated that 11% to 60% of unilateral slipped capital femoral epiphysis (SCFE) patients will develop contralateral pathology, usually within 18 months after the first event. Despite this, prophylactic fixation remains controversial, and there is significant variability in surgeon preferences. Thus, this study aimed to determine which factors predict surgeon preferences for prophylactic contralateral pinning in SCFE patients.

METHODS

We designed a survey for pediatric orthopedic surgeons to collect data on (1) surgeon and hospital characteristics, (2) individual preference for contralateral SCFE pinning in three disparate hypothetical scenarios, and (3) personal risk-aversion traits. The questionnaire was distributed across the United States by the POSNA Evidence-Based Orthopaedics Committee. All POSNA members were eligible to respond. We performed analyses to evaluate the role of patient risk factors in hypothetical surgical decision-making and to determine if surgical training, hospital characteristics, and geographic region influenced prophylactic pinning in a surgeon's real-life practice.

RESULTS

A total of 126 POSNA members responded to the survey. In the last year, a median of 6.5 SCFE patients was seen per surgeon (1243 patients total). A median of 10% of those patients underwent prophylactic contralateral fixation. In multiple analyses, surgeons were influenced by body mass index, open triradiate cartilage, patient race, various endocrine abnormalities, and specific radiographic measurements when deciding to fix the contralateral side prophylactically. Moreover, in multivariate regression, more years in practice and a hospital size of 500+ beds predicted fewer prophylactic fixation procedures (all P <0.05). Surgeons practicing in the South Atlantic, New England, and Mountain regions of the United States estimated the highest rate of contralateral pinning.

CONCLUSIONS

This study's findings suggest that multiple factors influence surgeons' decisions to prophylactically fix the contralateral side in SCFE patients. Surgical training, hospital characteristics, and geographical regions played a role in decision-making.

LEVEL OF EVIDENCE

N/A.

Evaluating consensus and uncertainty among treatment options for early-onset scoliosis: new generation and international perspectives

PURPOSE

It is currently unknown how treatment preferences differ between a senior group of U.S. spinal surgeons, a new generation of U.S. surgeons, and non-U.S. surgeons with regard to the treatment of early-onset scoliosis (EOS). The purpose of this study was to evaluate clinical consensus and uncertainty among treatment options for patients with EOS to understand how they compare between these three cohorts.

METHODS

11 senior pediatric spinal deformity surgeons in the U.S., 12 "junior" surgeons in the U.S., and 7 surgeons practicing in non-U.S. countries were invited to complete a survey of 315 idiopathic and neuromuscular EOS case scenarios. Treatment options included: conservative management, distraction-based methods, growth guidance/modulation, and arthrodesis. Consensus was defined as ≥ 70% agreement, and uncertainty was < 70%. Chi-squared and multiple regression analyses were performed to evaluate the associations between case characteristics and consensus for different treatments.

RESULTS

Although all 3 cohorts of surgeons chose conservative management most frequently, the non-U.S. cohort of surgeons chose distraction-based methods more often, particularly for neuromuscular cases. In both U.S. surgeon cohorts, there was consensus for conservative management in idiopathic patients aged 3 or younger regardless of other factors, whereas non-U.S. surgeons selected distraction-based methods for some of these patients.

CONCLUSION

Just as research studies are being conducted to find approaches to optimally manage the EOS population, future research efforts should focus on identifying the reasoning behind treatment preferences in different cohort of surgeons, as this will allow the interexchange of information which can ultimately improve EOS care.

LEVEL OF EVIDENCE

V.

International Society of University Colon and Rectal Surgeons survey of surgeons' preference on rectal cancer treatment

PURPOSE

Rectal cancer treatment has a wide range of possible approaches from radical extirpative surgery to nonoperative watchful waiting following chemoradiotherapy, with or without, additional chemotherapy. Our goal was to assess the personal opinion of active practicing surgeons on rectal cancer treatment if he/she was the patient.

METHODS

A panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) selected 10 questions that were included in a questionnaire that included other items including demographics. The questionnaire was distributed electronically to ISUCRS fellows and other surgeons included in our database and remained open from April 16 to 28, 2020.

RESULTS

One hundred sixty-three specialists completed the survey. The majority of surgeons (n=65, 39.9%) chose the minimally invasive (laparoscopic) surgery for their personal treatment of rectal cancer. For low-lying rectal cancer T1 and T2, the treatment choice was standard chemoradiation+local excision (n=60, 36.8%) followed by local excision±chemoradiotherapy if needed (n=55, 33.7%). In regards to locally advanced low rectal cancer T3 or greater, the preference of the responders was for laparoscopic surgery (n=65, 39.9%). We found a statistically significant relationship between surgeons' age and their preference for minimally invasive techniques demonstrating an age-based bias on senior surgeons' inclination toward open approach.

CONCLUSION

Our survey reveals an age-based preference by surgeons for minimally invasive surgical techniques as well as organ-preserving techniques for personal treatment of treating rectal cancer. Only 1/4 of specialists do adhere to the international guidelines for treating early rectal cancer.

An assessment of the variation in the practice of lumbar discectomy and its role in axial back pain

Background

Lumbar discectomy is performed for symptomatic lumbar disc herniation and is one of the most widely performed spinal surgical procedures worldwide in a variety of ways. This survey aimed at providing an overview/perspective of different practice patterns and the impact of lumbar discectomy on axial back pain with or without sciatica.

Methods

An online survey was performed using the application "Google Forms." The link to the questionnaire was distributed to neurosurgeons through personal E-mail and social media platforms.

Results

We received 333 responses. The largest percentage of responses across five continents was from Asia (66.97%, n = 223). The mean age of the respondents was 40.08 ± 10.5 years. A total of 66 respondents (20%) had a spine practice of 7%-90%, and 28 respondents had a spine practice of 90%-100% (8.4%). The number of respondents who practiced microscopic discectomy using a tubular retractor (n = 143 respondents, 42.9%) was nearly equal to the number of respondents who practiced open discectomy (n = 142 respondents, 42.6%). An almost equal proportion of respondents believed discectomy does not help in relieving axial back pain. Only 20.4% (n = 68) of respondents recommend bed rest for a longer duration postoperatively.

Conclusions

Our survey revealed that only 22.2% of spine surgeons recommended discectomy in patients with radiological disc herniation with axial back pain alone and preferred a minimally invasive method of discectomy. Almost half of them believed discectomy to be ineffective for axial low back pain and only a few recommended prolonged bed rest postoperatively.

Interventions for sustainable surgery: a systematic review

OBJECTIVE

To systematically evaluate interventions designed to improve the sustainability of surgical practice with respect to their environmental and financial impact.

BACKGROUND

Surgery contributes significantly to emissions attributed to healthcare due to its high resource and energy use. Several interventions across the operative pathway have, therefore, been trialed to minimize this impact. Few comparisons of the environmental and financial effects of these interventions exist.

MATERIALS AND METHODS

A search of studies published up to 2nd February 2022 describing interventions to increase surgical sustainability was undertaken. Articles regarding the environmental impact of only anesthetic agents were excluded. Data regarding environmental and financial outcomes were extracted with a quality assessment completed dependent upon the study design.

RESULTS

In all, 1162 articles were retrieved, of which 21 studies met inclusion criteria. Twenty-five interventions were described, which were categorized into five domains: 'reduce and rationalize', 'reusable equipment and textiles', 'recycling and waste segregation', 'anesthetic alternatives', and 'other'. Eleven of the 21 studies examined reusable devices; those demonstrating a benefit reported 40-66% lower emissions than with single-use alternatives. In studies not showing a lower carbon footprint, the reduction in manufacturing emissions was offset by the high environmental impact of local fossil fuel-based energy required for sterilization. The per use monetary cost of reusable equipment was 47-83% of the single-use equivalent.

CONCLUSIONS

A narrow repertoire of interventions to improve the environmental sustainability of surgery has been trialed. The majority focuses on reusable equipment. Emissions and cost data are limited, with longitudinal impacts rarely investigated. Real-world appraisals will facilitate implementation, as will an understanding of how sustainability impacts surgical decision-making.

Clinicians' perceptions around discectomy surgery for lumbar disc herniation: a survey of orthopaedic and neuro-surgeons in Australia and New Zealand

INTRODUCTION

Understanding practice-based differences in treatment of lumbar disc herniations (LDHs) is vital for reducing unwarranted variation in the delivery of spine surgical health care. Identifying factors that influence surgeons' decision-making will offer useful insights for developing the most cost-effective and safest surgical strategy as well as developing surgeon education materials for common lumbar pathologies. This study was to capture any variation in techniques used by surgeons in Australia and New Zealand (ANZ) region, and perceived complications of different surgical procedures for primary and recurrent LDH (rLDH).

MATERIALS AND METHODS

Web-based survey study was emailed to orthopaedic and neurosurgeons who routinely performed spinal surgery in ANZ from Decmber 20, 2018 to February 20, 2020. The response data were analyzed to assess for differences based on geography, practice setting, speciality, practice experience, practice length, and operative volume.

RESULTS

Invitations were sent to 150 surgeons; 96 (64%) responded. Most surgeons reported microdiscectomy as their surgical technique of choice for primary LDH (73%) and the first rLDH (72%). For the second rLDH, the preferred choice for most surgeons was fusion surgery (82%). A surgeon's practice setting (academic/private/hybrid) was a statistically significant factor in what surgical procedure was chosen for the first rLDH (P = 0.014). When stratifying based on surgeon experience, there were statisfically significant differences based on the annual volume of spine surgeries performed (perceived reherniation rates following primary discectomy, P = 0.013; perceived reherniation rates following revision surgeries, P = 0.017; perceived intraoperative complications rates following revision surgeries, P = 0.016) and based on the annual volume of lumbar discectomies performed (perceived reherniation rates following revision surgeries, P = 0.022; perceived intraoperative complications rates following revision surgeries, P = 0.036; perceived durotomy rates following primary discectomy, P = 0.023).

CONCLUSIONS

Surgeons' annual practice volume and practice setting have significant influences in the selection of surgical procedures and the perception of surgical complications when treating LDHs.

Protective ileostomy creation after anterior resection of the rectum: Shared decision-making or still subjective?

AIM

The choice of whether to perform protective ileostomy (PI) after anterior resection (AR) is mainly guided by risk factors (RFs) responsible for the development of anastomotic leakage (AL). However, clear guidelines about PI creation are still lacking in the literature and this is often decided according to the surgeon's preferences, experiences or feelings. This qualitative study aims to investigate, by an open-ended question survey, the individual surgeon's decision-making process regarding PI creation after elective AR.

METHOD

Fifty four colorectal surgeons took part in an electronic survey to answer the questions and describe what usually led their decision to perform PI. A content analysis was used to code the answers. To classify answers, five dichotomous categories (In favour/Against PI, Listed/Unlisted RFs, Typical/Atypical, Emotions/Non-emotions, Personal experience/No personal experience) have been developed.

RESULTS

Overall, 76% of surgeons were in favour of PI creation and 88% considered listed RFs in the question of whether to perform PI. Atypical answers were reported in 10% of cases. Emotions and personal experience influenced surgeons' decision-making process in 22% and 49% of cases, respectively. The most frequently considered RFs were the distance of the anastomosis from the anal verge (96%), neoadjuvant chemoradiotherapy (88%), a positive intraoperative leak test (65%), blood loss (37%) and immunosuppression therapy (35%).

CONCLUSION

The indications to perform PI following rectal cancer surgery lack standardization and evidence-based guidelines are required to inform practice. Until then, expert opinion can be helpful to assist the decision-making process in patients who have undergone AR for adenocarcinoma.

Biomechanical effects of cross-pin's diameter in reconstruction of anterior cruciate ligament - A specific case study via finite element analysis

For anterior cruciate ligament reconstruction (ACL-R), one of the crucial aspects of treatment is the fixator selection that could provide initial graft fixation post-operatively. Literature on biomechanical stabilities of different sizes of fixators as femoral graft fixation is limited. Therefore, this study aims to analyse the influence of different diameters of cross-pins on the stability of graft fixations after ACL-R via finite element analysis (FEA). In the methodology, three-dimensional (3D) models of three different diameters of cross-pins were developed, of which anterior tibial loads (ATL) were applied onto the tibia. From the findings, the cross-pin with a smaller diameter (4 mm) provided optimum stability than larger diameter cross-pins, whereby it demonstrated acceptable stresses at the fixators (both cross-pin and interference screw) with a different percentage of 28%, while the stresses at the corresponding bones were favourable for osseointegration to occur. Besides, the strains of the knee joint with 4 mm diameter cross-pin were also superior in providing a good biomechanical environment for bone healing, while the recorded strain values at fixators were comparable with a larger diameter of cross-pins without being inferior in terms of deformation. To conclude, the cross-pin with 4 mm diameter depicted the best biomechanical aspects in graft fixation for ACL-R since it allows better assistance for the osseointegration process and can minimise the possibility of the breakage and migration of fixators. This study is not only useful for medical surgeons to justify their choices of pin diameter to treat patients, but also for researchers to conduct future studies.

Collaborative Review: Factors Influencing Treatment Decisions for Patients with a Localized Solid Renal Mass

CONTEXT

With the addition of active surveillance and thermal ablation (TA) to the urologist's established repertoire of partial (PN) and radical nephrectomy (RN) as first-line management options for localized renal cell carcinoma (RCC), appropriate treatment decision-making has become increasingly nuanced.

OBJECTIVE

To critically review the treatment options for localized, nonrecurrent RCC; to highlight the patient, renal function, tumor, and provider factors that influence treatment decisions; and to provide a framework to conceptualize that decision-making process.

EVIDENCE ACQUISITION

A collaborative critical review of the medical literature was conducted.

EVIDENCE SYNTHESIS

We identify three key decision points when managing localized RCC: (1) decision for surveillance versus treatment, (2) decision regarding treatment modality (TA, PN, or RN), and (3) decision on surgical approach (open vs minimally invasive). In evaluating factors that influence these treatment decisions, we elaborate on patient, renal function, tumor, and provider factors that either directly or indirectly impact each decision point. As current nomograms, based on preselected patient datasets, perform poorly in prospective settings, these tools should be used with caution. Patient decision aids are an underutilized tool in decision-making.

CONCLUSIONS

Localized RCC requires highly nuanced treatment decision-making, balancing patient- and tumor-specific clinical variables against indirect structural influences to provide optimal patient care.

PATIENT SUMMARY

With expanding treatment options for localized kidney cancer, treatment decision is highly nuanced and requires shared decision-making. Patient decision aids may be helpful in the treatment discussion.

The laparoscopy in emergency general surgery (LEGS) study: a questionnaire survey of UK practice

INTRODUCTION

Recent consensus guidelines suggest that the laparoscopic approach may be a useful, safe and feasible approach in emergency general surgery. Despite this, the UK National Emergency Laparotomy Audit (NELA) suggests the rate of laparoscopy is low (9% fully laparoscopic) and slow to increase over time. A European survey found uptake to be variable. This UK survey was therefore undertaken to establish current UK practice and to determine factors affecting implementation.

MATERIALS AND METHODS

A questionnaire survey of currently practising UK consultant general surgeons was carried out by the North West Surgical Research Collaborative, using a secure web-based database maintained by the North West Surgical Trials Centre.

RESULTS

A total of 151 completed questionnaires were returned from 22 UK centres; 18% of respondents were unaware that laparoscopic cases should be reported to NELA. Appendicectomy (97%) and cholecystectomy (87%) were routinely performed laparoscopically. Laparoscopy was infrequently used in perforation, ischaemia or obstructed hernias. There appears to be equipoise regarding laparoscopic compared with open surgery in small-bowel obstruction among all subspecialty emergency general surgeons, in perforated peptic ulcer among upper gastrointestinal surgeons and in Hinchey III diverticulitis among colorectal surgeons.

CONCLUSION

Uptake of laparoscopy in UK emergency general surgery is influenced by surgeon preference, subspecialty, patient and operative factors. Further research into outcomes may help to identify areas of greatest potential benefit. The rate of laparoscopy reported by NELA may be an underestimate due to the 18% of surgeons unaware that laparoscopic cases should be reported, which may affect the validity of analyses performed from this dataset.

Quality Improvement: Arterial Grafting Redux, 2010:2019

BACKGROUND

The evidence base favoring utilization of multiple arterial conduits in coronary artery bypass grafting has strengthened in recent years. Nevertheless, utilization of arterial conduits in the US lags behind that of many European peers. We describe a statewide collaborative based approach to improving utilization.

METHODS

Four metrics of arterial revascularization were devised. These were displayed and discussed at quarterly statewide quality collaborative meetings from January 2016 onwards, integrated with an educational program regarding attendant benefits. We undertook retrospective review of isolated coronary artery bypass grafting statewide from 2012-2019 to assess impact.

RESULTS

A total of 38,523 cases met inclusion/exclusion criteria. Statewide incidence of multiple arterial grafting increased from 7.4% at baseline to 21.7% in 2019 (P < .001), implementation across hospitals varied widely, ranging from 67.6% to 0.0%. Utilization of total arterial revascularization increased 1.9% to 4.4% (P < .001) between time frames. Utilization of both radial artery and bilateral internal thoracic artery conduit increased significantly from 5.3% to 13.2% (P < .001) and 2.1% to 8.5% (P < .001), respectively; radial artery utilization was significantly higher than bilateral internal thoracic artery for each year (P < .001 for all comparisons).

CONCLUSIONS

Our statewide quality improvement initiative improved rates of utilization of multiple arterial grafting by all metrics. Barriers to current utilization were identified to guide future quality improvement efforts. This reproducible approach is readily transferable to improve quality of care in other domains and geographical areas.

BIOMECHANICAL EFFECTS OF DIFFERENT LENGTHS OF CROSS-PINS IN ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION: A FINITE ELEMENT ANALYSIS

Complication rates of anterior cruciate ligament reconstruction (ACL-R) were reported to be around 15%. Although it is a very common arthroscopic surgery with good outcomes, breakage and migration of fixators are still possible to occur due to stability issue. One of the factors that affects the mechanical stability of fixators is its length. Therefore, the aim of this paper is to analyze the biomechanical effects of different lengths of fixators (cross-pin technique) towards the stabilities of the knee joint after ACL-R. Finite element analyses of knee joint with DST grafts and fixators were carried out. Mimics and 3-Matic were used in the development of knee joint models, while the grafts and fixators were designed by using SolidWorks software. All models were remeshed in the 3-Matic and numerical analysis was performed via MSC.Marc Mentat software. A 100 N anterior tibial load was applied onto the tibia to simulate the anterior drawer test after the surgery and proximal femur was fixed at all degrees of freedom. Based on the findings, cross-pin with 40[Formula: see text]mm in length provided the most favorable option for better treatment of ACL-R, where it could promote osseointegration and preventing fracture.

The rendezvous technique for the treatment of ipsilateral femoral neck and shaft fractures: A case series

Concomitant ipsilateral femoral neck and shaft fractures are uncommon high-energy injuries characteristically occurring in young adults. Between 75 and 100% of these injuries occur in association with polytrauma to other organ systems. Associated femoral neck fractures are typically undisplaced, occurring in 2–9% of all femoral shaft fractures. These injuries present both technical and infrastructural challenges particularly in a low resource environment. Several methods of treatment have been used to successfully treat these fractures but there exists no consensus about the optimal management strategy. The “rendezvous” technique using dual implants in an overlapping fashion has been proposed as one method to treat these fractures. We present three cases of ipsilateral hip and femoral shaft fractures which were satisfactorily treated using this technique. The “rendezvous” technique is a simple method, with a good clinical outcome and a low complication rate that can be used to treat ipsilateral femoral neck and shaft fractures.

Buruli ulcer treatment: Rate of surgical intervention differs highly between treatment centers in West Africa

Background

Antibiotic treatment proved itself as the mainstay of treatment for Buruli ulcer disease. This neglected tropical disease is caused by Mycobacterium ulcerans. Surgery persists as an adjunct therapy intended to reduce the mycobacterial load. In an earlier clinical trial, patients benefited from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic.

Methods

A retrospective study was conducted in six different Buruli ulcer (BU) treatment centers in Benin and Ghana. BU patients clinically diagnosed between January 2012 and December 2016 were included and surgical interventions during the follow-up period, at least one year after diagnosis, were recorded. Logistic regression analysis was carried out to estimate the effect of the treatment center on the decision to perform surgery, while controlling for interaction and confounders.

Results

A total of 1193 patients, 612 from Benin and 581 from Ghana, were included. In Benin, lesions were most frequently (42%) categorized as the most severe lesions (WHO criteria, category III), whereas in Ghana lesions were most frequently (44%) categorized as small lesions (WHO criteria, category I). In total 344 (29%) patients received surgical intervention. The percentage of patients receiving surgical intervention varied between hospitals from 1.5% to 72%. Patients treated in one of the centers in Benin were much more likely to have surgery compared to the clinic in Ghana with the lowest rate of surgical intervention (RR = 46.7 CI 95% [17.5–124.8]). Even after adjusting for confounders (severity of disease, age, sex, limitation of movement at joint at time of diagnosis, ulcer and critical sites), rates of surgical interventions varied highly.

Conclusion

The decision to perform surgery to reduce the mycobacterial load in BU varies highly per clinic. Evidence based guidelines are needed to guide the role of surgery in the treatment of BU

Buruli ulcer is a necrotizing and disabling skin infection, caused by Mycobacterium ulcerans. The infection, a skin-related Neglected Tropical Diseases, affects mostly people living in limited resources settings. Since the introduction of rifampicin based combination antibiotic therapy as standard care, the role of surgery as adjunct therapy to kill M. ulcerans is less defined and understood. A randomized controlled trial showed benefit from delaying the decision to operate. Nevertheless, the rate of surgical interventions differs highly per clinic. We present the differences in rate of surgical interventions in six different Buruli ulcer treatment centers in Ghana and Benin. We demonstrate that these differences mainly depend on the opinion of the health care workers working in the treatment centers even after adjusting for disease severity.