Telesurgery prospects in delivering healthcare in remote areas

Feasibility and safety of performing remote surgery was first established by performing surgeries on pigs in later part of the 20th century. The first tele-robotic remote surgical system was set up in Canada in 2003 between two hospitals 400 kilometres away. The current review was planned to have a look at the current state of robotic surgery and its use in telesurgery. Literature search was conducted for articles related to Robotic Surgery and Tele-Surgery . Our search included articles published in English literature, including case studies and review articles. We searched Google Scholar and PubMed to search relevant articles. Introduction of haptic feedback technology added significantly to safety robotic surgery. Tele-surgery, also called tele-robotics, combines the advantages of robotic surgery, including magnified view, augmented reality and improved ergonomics and dexterity, and provision of surgical care in remote areas and difficult-to-reach locations like spacecrafts and ships. Challenges, like cost, availability and legislations, remain to be addressed

Fifteen years experience of managing penetrating extra-peritoneal rectal injuries

Background: Although civilian injuries are generally less severe, they nevertheless remain a challenging problem for the surgeons. In isolated rectal injury patients, though proximal diversion, pre-sacral drainage, distal rectal wash-out and wound debridement are the various surgical options employed in various combinations, the optimum strategy especially for civilian injuries remains unknown. We reviewed our experience of managing penetrating extra peritoneal rectal injuries. Methods: We conducted a Retrospective review of Adult patients with penetrating extra-peritoneal rectal injuries. Follow-up information of at least one month was needed for early post-operative complications. Results: A total number of fifteen patients met inclusion criteria. Median age of our patients was 46 years with range being 20-80 years. All our patients were males. Thirteen of our patients (86%) suffered from gunshot injury while one was a blast victim and one had a stab injury to rectum. Nine patients (60%) had pelvic fracture associated with rectal injury. Diversion stoma was made in all of our patients. Overall post-operative morbidity was 40%. Two patients developed necrotizing fasciitis and required repeated debridements followed by graft placement and one patient developed intra-abdominal abscess which was treated by radiological guided drain placement and antibiotics. Conclusion: Drainage with fecal diversion is the most commonly employed management of extra-peritoneal rectal injuries. Delayed or inadequate drainage can lead to disastrous consequences including necrotizing fasciitis, intra-abdominal abscess

Template operative note: A better documentation

Operative notes are a valuable part of patient\u27s medical record, and carry the medico-legal significance. One way of improving it is to introduce the template form operative notes. Only few studies have been done worldwide to compare both the forms of operative notes. This cross-sectional study was conducted in the department of General Surgery, AKUH. This included the patients who underwent Laparoscopic cholecystectomy (Complying with inclusion criteria) from August 2013 till March 2014. Out of 24 patients, 19 were females. The completeness of data in template group was significantly better than traditional group (79.2% vs. 8.3%). There was no significant difference among the residents of different level (writing the notes) and the completeness of data in both the groups. Similarly the timing of day did not affect significantly on the completeness

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study

Background: The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on postoperative recovery needs to be understood to inform clinical decision making during and after the COVID-19 pandemic. This study reports 30-day mortality and pulmonary complication rates in patients with perioperative SARS-CoV-2 infection. Methods: This international, multicentre, cohort study at 235 hospitals in 24 countries included all patients undergoing surgery who had SARS-CoV-2 infection confirmed within 7 days before or 30 days after surgery. The primary outcome measure was 30-day postoperative mortality and was assessed in all enrolled patients. The main secondary outcome measure was pulmonary complications, defined as pneumonia, acute respiratory distress syndrome, or unexpected postoperative ventilation. Findings: This analysis includes 1128 patients who had surgery between Jan 1 and March 31, 2020, of whom 835 (74·0%) had emergency surgery and 280 (24·8%) had elective surgery. SARS-CoV-2 infection was confirmed preoperatively in 294 (26·1%) patients. 30-day mortality was 23·8% (268 of 1128). Pulmonary complications occurred in 577 (51·2%) of 1128 patients; 30-day mortality in these patients was 38·0% (219 of 577), accounting for 81·7% (219 of 268) of all deaths. In adjusted analyses, 30-day mortality was associated with male sex (odds ratio 1·75 [95% CI 1·28–2·40], p\textless0·0001), age 70 years or older versus younger than 70 years (2·30 [1·65–3·22], p\textless0·0001), American Society of Anesthesiologists grades 3–5 versus grades 1–2 (2·35 [1·57–3·53], p\textless0·0001), malignant versus benign or obstetric diagnosis (1·55 [1·01–2·39], p=0·046), emergency versus elective surgery (1·67 [1·06–2·63], p=0·026), and major versus minor surgery (1·52 [1·01–2·31], p=0·047). Interpretation: Postoperative pulmonary complications occur in half of patients with perioperative SARS-CoV-2 infection and are associated with high mortality. Thresholds for surgery during the COVID-19 pandemic should be higher than during normal practice, particularly in men aged 70 years and older. Consideration should be given for postponing non-urgent procedures and promoting non-operative treatment to delay or avoid the need for surgery. Funding: National Institute for Health Research (NIHR), Association of Coloproctology of Great Britain and Ireland, Bowel and Cancer Research, Bowel Disease Research Foundation, Association of Upper Gastrointestinal Surgeons, British Association of Surgical Oncology, British Gynaecological Cancer Society, European Society of Coloproctology, NIHR Academy, Sarcoma UK, Vascular Society for Great Britain and Ireland, and Yorkshire Cancer Research

PANC Study (Pancreatitis: A National Cohort Study): national cohort study examining the first 30 days from presentation of acute pancreatitis in the UK

Abstract Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions. </jats:sec

Predictors of missed hospital appointments in patients with posterior compartment pelvic floor disorders in a tertiary referral centre

Aim:: Missed hospital appointments pose a major challenge to the healthcare system leading to worse patient outcomes. We ascertained the incidence of missed hospital appointments in patients with Posterior Compartment Pelvic Floor Disorders (PC-PFD) and associated socio-demographic and clinical predictors. Methods:: This is a cross-sectional single-institution study from a tertiary pelvic floor unit (PFU) with data collected from a prospectively maintained database.A missed appointment was marked if patients did not​ attend two consecutive appointments without informing or asking to re-schedule and were recorded for Telephone Triage Assessment Clinic (TTAC), Specialist-nurse, face-to-face bowel function clinic (BFC), Investigations including endoanal (EAUS) and pelvic floor ultrasound (PFUS) and defaecating proctogram (DP). All results yielding p<0.05 were considered significant. Results:: PFU received 2001 referrals between 2013 and 2019 with a mean age of 52 years. Missed appointments recorded were: TTAC — 45 (2.2%), BFC — 309 (15.8%), EAUS — 476(24%), PFUS — 484(37.2%) and DP — 432(26.2%).Predictors determined were: Male gender, age <50 years, complaints of rectal pain and bleeding for missing telephone and face-to-face appointments, low socioeconomic status for missing face-to-face appointments, and mixed and other ethnic groups with missing telephone appointments. Conclusion:: This is the first study to report the incidence and socio-demographic and clinical predictors for missed appointments in patients with PC-PFD. Future prospective research, including qualitative studies interviewing patients, is needed to identify and address potential barriers patients face when accessing care for PC-PFD. This will help improve patient care and allow better utilisation of already constrained healthcare resources

Is there any association between socio-demographic characteristics and presenting complaints in patients with posterior compartment pelvic floor disorders?

Introduction:: Posterior compartmental pelvic floor disorders (PC-PFD) include symptoms of anal incontinence, obstructed defaecation (ODS) and functional anal pain [1]. According to the pelvic floor report in 2021, 6.5 million people suffered from bowel problems in the UK.We determined the association of socio-demographic and clinical characteristics with presenting complaints in patients with PC-PFD and prevalence of the type of presenting complaint. Methods:: This is a cross-sectional single-institution study of patients with (PC-PFD)reviewed in a tertiary pelvic floor unit between 2013 and 2019. Data was collected for socio-demographics from a prospectively maintained database and retrospectively for clinical factors. Results:: Initial appointment was attended by 1956 patients with a mean age of 52.9 +/−15.5 years. The. Main presenting complaints reported were obstructive defaecation (ODS – n = 819, 42.2%), anal incontinence (AI) (503, 25.9%), mixed (ODS and AI) (411, 21.2%), rectal prolapse (84, 4.3%), other complaints (rectal pain or bleeding – n=84, 4.3%) and symptoms of vaginal prolapse (38,2.1%).ODS was associated with age < 50 years, female gender and episiotomy while AI was associated with parity and prior hysterectomy and pelvic floor surgery. Rectal prolapse was associated with female gender while other complaints with age < 50 years. Conclusion:: This study reports socio-demographic and clinical risk factors associated with presenting complaints in patients with PC-PFD. This can form a basis for future prospective research to take initiatives for creating awareness about PC-PFD and identify symptoms in high-risk patients early to offer treatment or make timely referral from the community or primary care

Exploring the cost-effectiveness of high versus low perioperative fraction of inspired oxygen in the prevention of surgical site infections among abdominal surgery patients in three low- and middle-income countries

Background: This study assessed the potential cost-effectiveness of high (80-100%) vs low (21-35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was$216 compared with $222 for low FiO2 leading to a -$6 (95% confidence interval [CI]: -$13 to -$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with$195 for low FiO2 leading to a -$11 (95$15 to -$6) difference in costs. In South Africa, the average cost for high FiO2 was$1164 compared with $1257 for low FiO2 leading to a -$93 (95% CI: -$132 to -$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a -1.05 (95% CI: -1.14 to -0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm thi