Novel accessory safety footswitch permitting dual control of surgical electrical diathermy: an asset in risk management in surgical training?

Introduction: Human error contributes to the majority of adverse events in the operating theatre environment. Many processes exist to limit the incidence of such adverse events. However, the role of technology and device advancement has been limited in this respect. Methods: A dual-controlled accessory electrical diathermy footswitch (abortive diathermy footswitch device or ADF) concept was developed in an attempt to improve patient safety in theatre. The activation of the ADF allows a senior surgeon to control the activation of diathermy devices by a junior surgeon by deactivating diathermy devices when the ADF footswitch is operated. Results: The ADF device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was clinically tested during two separate theatre sessions involving five elective laparoscopic cholecystectomies. Conclusions: We demonstrated the feasibility and functionality of the ADF device and propose a role in surgical training through potentially limiting surgical errors associated with the use of electrical diathermy during training and expanding accessible surgical experience

Can neutrophil-lymphocyte ratio predict operators’ difficulty in early cholecystectomies; a retrospective cohort study

Background: Recent years has seen an increased trend toward “early cholecystectomy” following acute cholecystitis. Operators whilst performing cholecystectomy during acute cholecystitis commonly finds varying degree of inflammation ranging from soft omental adhesions to densely adherent gangrenous gall bladder, which is not only associated with morbidity but is often technically challenging. In this study we aim to retrospectively evaluate the role of neutrophil-lymphocyte ratio (NLR) and its association with operative difficulty and length of stay for patients who underwent ‘hot cholecystectomy’. Methods: An anonymised retrospective single-centre cohort study using operative notes and clinical data. Chi-squared test and Mann-Whitney U-test were applied to determine significance between variables in the predetermined low NLR (5) groups. Multiple linear regression was applied for assessing any significant relationships between NLR and operative difficulty, length of stay (LOS) and post-operative stay (POS). Results: Patients with a high NLR > 5 level upon admission are on average older (median 44 vs 60 years; p-value 0.003), have a longer hospital stay (median 4 vs 5 days; 0.005), their operations takes longer (median 81 vs. 98 minutes; p=0.026), and operations are deemed more difficult (13% vs. 33%; p=0.035) as judged by surgeons and evident by intra operative parameters. In linear regresseion increased age was found to be associated with higher NLR (p=0.035). Presence of gangrene was significantly associated with both LOS and POS in regression analysis (p-value 0.044 and 0.015 respectively). Conclusions: In performing an ‘early cholecystectomy’ a higher NLR on admission is associated with operators’ difficulty. However, a NLR cut off of 5 is not significantly linked to increased length of stay. Nonetheless, NLR on admission can be applied to stratify acute cholecystitis to plan surgery and anticipate difficult operation. NLR when combined with age can be utilised as guide to prioritise the urgency of operation and as prognostic predictor of possible post op complications

Diagnostic accuracy of CRP & WCC in abdomino-pelvic diseases of non-traumatic acute abdomen by taking CT findings as gold standard

Acute abdomen is a common presentation to many emergency departments worldwide. It is important to differentiate self-limiting causes and serious surgical causes. Inflammatory markers such as WCC and CRP currently being used to determine the cause, assess severity and guide further investigation for acute abdomen. The aim of this study was to determine diagnostic accuracy of C - reactive protein and White Cell Count in abdomino-pelvic diseases of non-traumatic acute abdomen by taking CT scan findings as gold standard. We found that CRP levels of above 100 were highly sensitive (94%) and specific (92%) for an acute surgical abdomen. WCC was not as accurate at determining an acute surgical abdomen due to reasons such as neutropenic sepsis

Impact of COVID-19 on Laparoscopic Surgery: A Short Survey of the Surgeons Working at the Frontline in this Pandemic

Introduction: COVID-19 poses serious risk to surgeons performing laparoscopic surgery. This risk can be exponential however scientific evidence to quantify this risk is lacking. Surgical community is divided in their opinion with regards to role of laparoscopy in COVID-19. Methods: We performed literature search to identify studies, guidance from major institutions to provide cumulative evidence and to formulate formal opinion on role of laparoscopy in COVID-19. We also performed short survey to assess the opinion of surgeons in this regards. Results: Literature search revealed guidelines from major surgical institutions, which were included in the study. Three papers published in the last few days did not report any patient’s data. Our survey revealed surgical community is divided in their opinion with regards to role of laparoscopy in surgery and stressed the need for more robust evidence. Conclusion: Surgeons are divided in their opinion as to whether or not to perform laparoscopic procedures during COVID-19 pandemic. Although guidelines have to be followed currently, there is more than urgent need for robust evidence

An overview of evidence-based management of hepatocellular carcinoma: A meta-analysis

Introduction: An increasing trend of incidence in hepatocellular carcinoma (HCC) has been recorded in most developed countries. HCC ranks among the ten most common cancers worldwide. The health costs and burden to the economy implicated by HCC are huge. In recent years, the surveillance programs and screening for the disease, in addition to increasing awareness, led to the detection of smaller precursor lesions of HCC in the liver. The rise of molecular-targeted therapies and the publication of various conflicting guidelines on the management of the disease demand a review of evidence into the curative therapies and medical management of HCC. Aims: The primary objective was to identify the survival benefit of the primary medical modalities in HCC, as more trials were uncovered between 2005 and 2010. The secondary objective was to conduct a meta-analysis. Selection criteria were implemented to select randomized controlled trials (RCTs), to include in this study. After selection, all the articles were ranked according to their strength. Materials and Methods: The MEDLINE, CANCERLIT, Embase databases, and the Cochrane Library were reviewed using the national library of health website. The time limit used for searching for RCTs was between January 2005 and December 2010. Overall survival and the cumulative probability of no recurrence were the primary endpoints considered in the studies to be assessed. These endpoints were measured over one, two, or three years, depending on the size of the study and the length of follow-up. The software package comprehensive meta-analysis ver 2.0.exe (Biostat, USA) was used to comply with the results, to conduct the meta-analysis, and help with analyzing the data. Results: The original general search yielded 193 RCTs between 2005 and 2010. Only 32 studies met the inclusion criteria. However, after the ranking of the studies according to strength, only 17 studies were eventually selected. The 17 studies were subsequently classified according to the following; surgical resection (n = 2); percutaneous treatments (n = 5); chemoembolization (n = 1); systemic treatments (n = 8); and other treatments (n = 1). Randomized studies comparing the percutaneous ethanol injection (PEI) to the surgical resection were inconclusive. However, percutaneous treatments showed results similar to surgical resection in terms of overall survival. The meta-analysis comparing PEI to radiofrequency ablation (RFA) showed RFA to be superior to PEI in terms of overall survival at three years (odds ratio 1.698; 95% CI 1.206 - 2.391; P = 0.002). When adverse events were considered there was no statistically significant difference between the RFA and PEI groups (odds ratio 1.199; 95% CI 0.571- 2.521; P = 0.632). Conclusion: RFA should be the first-line treatment in patients with a single small HCC tumor ≤ 3 cm. Careful patient selection is crucial prior to transarterial chemoembolization (TACE), as the procedure may be associated with an increased risk of liver failure. Tamoxifen has no role to play in the treatment of HCC. Sorafenib should be the first-line treatment in patients with advanced and inoperable HCC. The role of Sorafenib in the management of early stage HCC remains to be determined

A Novel Dual-Phase Activation-Dependent Foot-Switch Mechanism for Surgical Energy Devices as an Asset in Early Surgical Training: A Proof of Concept Study

Introduction. Many processes exist that limit or eliminate the incidence of adverse events in general surgery including the World Health Organization safety checklist. Technology and device advancement has a potentially expanding role in the context of surgical safety. Materials and Methods. A dual controlled accessory electrical diathermy footswitch ( Permissive diathermy foot switch device or PDf) device concept was developed in an effort to improve patient safety in theatre and enhance opportunities in training. Electrical diathermy is only activated if the senior supervising surgeon and the novice surgeon simultaneously activate their interconnected footswitches. The activation of the PDf accessory footswitch device allows a senior surgeon to exert control on “initiation” of activation of diathermy devices operated by a novice surgeon ( foot on pedal) as well as when desiring to deactivate the device ( foot off pedal). Results. A process of designing and prototyping was initiated to define the purpose and the functionality of the PDf device up till the stage of a fully functioning prototype. The PDf device was constructed as a final working and tested prototype in association with the local medical engineering department at the Cumberland Infirmary in Carlisle. The device was on a nonbiological model to determine efficacy and safety and passed its laboratory testing phase and was deemed ready for clinical use. Conclusion. We demonstrated the feasibility and functionality of the PDf device and propose a positive role in surgical training in the context of early surgical training and specific circumstances where more control is needed

Effect of altitude on mortality of end-stage renal disease patients on hemodialysis in Peru

Background. In Latin America, the prevalence of end-stage kidney disease (ESKD) has risen tremendously during the last decade. Previous studies have suggested that receiving dialysis at high altitude confers mortality benefits; however, this effect has not been demonstrated at >2000 m above sea level (masl) or in developing countries. Methods. This historical cohort study analyzed medical records from six Peruvian hemodialysis (HD) centers located at altitudes ranging from 44 to 3827 masl. Adult ESKD patients who started maintenance HD between 2000 and 2010 were included. Patients were classified into two strata based on the elevation above sea level of their city of residence: low altitude (<2000 masl) and high altitude (2000 masl). Death from any cause was collected from national registries and Cox proportional hazards models were built. Results. A total of 720 patients were enrolled and 163 (22.6%) resided at high altitude. The low-altitude group was significantly younger, more likely to have diabetes or glomerulonephritis as the cause of ESKD and higher hemoglobin. The all-cause mortality rate was 84.3 per 1000 person-years. In the unadjusted Cox model, no mortality difference was found between the high- and low-altitude groups fhazard ratio [HR] 1.20 [95% confidence interval (CI) 0.89–1.62]g. After multivariable adjustment, receiving HD at high altitude was not significantly associated with higher mortality, but those with diabetes as the cause of ESKD had significantly higher mortality [HR 2.50 (95% CI 1.36–4.59)]. Conclusions. In Peru, patients receiving HD at high altitudes do not have mortality benefits