Burnout Among Surgeons in the UK During the COVID-19 Pandemic: A Cohort Study

BackgroundSurgeon burnout has implications for patient safety and workforce sustainability. The aim of this study was to establish the prevalence of burnout among surgeons in the UK during the COVID-19 pandemic.MethodsThis cross-sectional online survey was set in the UK National Health Service and involved 601 surgeons across the UK of all specialities and grades. Participants completed the Maslach Burnout Inventory and a bespoke questionnaire. Outcome measures included emotional exhaustion, depersonalisation and low personal accomplishment, as measured by the Maslach Burnout Inventory-Human Services Survey (MBI-HSS).ResultsA total of 142 surgeons reported having contracted COVID-19. Burnout prevalence was particularly high in the emotional exhaustion (57%) and depersonalisation (50%) domains, while lower on the low personal accomplishment domain (15%). Burnout prevalence was unrelated to COVID-19 status; however, the greater the perceived impact of COVID-19 on work, the higher the prevalence of emotional exhaustion and depersonalisation. Degree of worry about contracting COVID-19 oneself and degree of worry about family and friends contacting COVID-19 was positively associated with prevalence on all three burnout domains. Across all three domains, burnout prevalence was exceptionally high in the Core Trainee 1–2 and Specialty Trainee 1–2 grades.ConclusionsThese findings highlight potential undesirable implications for patient safety arising from surgeon burnout. Moreover, there is a need for ongoing monitoring in addition to an enhanced focus on mental health self-care in surgeon training and the provision of accessible and confidential support for practising surgeons

Identification of Surgeon Burnout via a Single-Item Measure

BackgroundBurnout is endemic in surgeons in the UK and linked with poor patient safety and quality of care, mental health problems, and workforce sustainability. Mechanisms are required to facilitate the efficient identification of burnout in this population. Multi-item measures of burnout may be unsuitable for this purpose owing to assessment burden, expertise required for analysis, and cost.AimsTo determine whether surgeons in the UK reporting burnout on the 22-item Maslach Burnout Inventory (MBI) can be reliably identified by a single-item measure of burnout.MethodsConsultant (n = 333) and trainee (n = 217) surgeons completed the MBI and a single-item measure of burnout. We applied tests of discriminatory power to assess whether a report of high burnout on the single-item measure correctly classified MBI cases and non-cases.ResultsThe single-item measure demonstrated high discriminatory power on the emotional exhaustion burnout domain: the area under the curve was excellent for consultants and trainees (0.86 and 0.80), indicating high sensitivity and specificity. On the depersonalisation domain, discrimination was acceptable for consultants (0.76) and poor for trainees (0.69). In contrast, discrimination was acceptable for trainees (0.71) and poor for consultants (0.62) on the personal accomplishment domain.ConclusionsA single-item measure of burnout is suitable for the efficient assessment of emotional exhaustion in consultant and trainee surgeons in the UK. Administered regularly, such a measure would facilitate the early identification of at-risk surgeons and swift intervention, as well as the monitoring of group-level temporal trends to inform resource allocation to coincide with peak periods

Study of the expression of cell cycle and angiogenic markers in patients with hepatocellular carcinoma that underwent curative hepatic resection: correlation with postoperative survival and classic clinicopathological prognostic parameters

HCC is a common, yet highly aggressive neoplasm with low survival rates. As a result, the better understanding of the biology of this disease and the finding of predictive biomarkers and new therapeutic targets is of particular scientific interest. The HCC usually develops in patients with hepatitis and cirrhosis, due to chronic inflammation and damage of the hepatocytes. On a molecular level, DNA damage and genomic instability are common features of the disease. Similar to any cancer, malignant cells in HCC acquire specific characteristics, hallmarks, that allows them to sustain proliferative signaling, evade growth suppressors, resist cell death, enable replicative immortality, induce angiogenesis, and activate invasion and metastasis. Genomic instability, characterized by accumulation of mutations, is one of the major mechanisms behind the development and progression of cancer. Alongside, DNA damage due to replicative stress and the DNA damage responses are considered cornerstones of oncogenesis. Cell cycle checkpoints play a very important role in the control of proliferation and in the maintenance of genomic integrity. An important control mechanism of the cell cycle is the licensing of DNA replication. The DNA replication licensing factors control DNA replication, preventing replicative stress and genomic instability. In addition, the IPP complex (ILK-parvin-PINCH), mainly on focal adhesions, by mediating the signalling between cells and extracellular matrix (ECM) and growth factors, controls proliferation, invasion, metastasis and angiogenesis.The aim of the present study, was to evaluate the expression of cell cycle and angiogenic markers in patients with hepatocellular carcinoma. We analysed formalin-fixed paraffin-embedded biopsy specimens from a total of 111 patients who underwent hepatectomy or curative resection for HCC. In those samples, we evaluated the role of DNA replication licensing factors Cdt1 and Mcm7, DDR factors p-H2AX, phospho-ATM/ATR and p53, angiogenetic factor VEGF-A, vascular density marker CD31 and the IPP complex (ΙLK, β-parvin και PINCH). Moreover, we evaluated the prognostic significance through correlations with the clinicopathological characteristics of HCC and the survival of the patients. Our study demonstrated that Cdt1 is overexpressed in HCC, correlates with tumor grade and TNM stage and is a predictor of poor survival in patients with HCC (p=0.049). In addition, we showed that Mcm7 is also overexpressed in HCC and correlates with DDR, although, no correlations were found with the clinicopathological characteristics of HCC and the survival of the patients. Interestingly, the DDR factors p-H2AX, phospho-ATM/ATR and p53 were overexpressed in HCC and were correlated with the expression of licensing factors Cdt1 and Mcm7. Furthermore, we found that ILK is overexpressed in HCC and correlates with the studied licensing, DDR and angiogenic factors and that β-parvin and PINCH are also overexpressed in HCC. Finally, we identified that growth factor VEGF-A is overexpressed in HCC and correlates with poor survival in patients with HBV and that vascular density factor CD31 is correlated with invasion in HCC.Further studies are needed to validate our results, to identify the link between DNA licensing deregulation and genomic instability in HCC, to delineate the role of the IPP complex and to explore any possible clinical applications.Το ΗΚΚ αποτελεί ένα πολύ συχνό και συνάμα εξαιρετικά επιθετικό νεόπλασμα με χαμηλά ποσοστά επιβίωσης. Ως αποτέλεσμα, η καλύτερη κατανόηση της βιολογίας της νόσου και η εύρεση προγνωστικών-προβλεπτικών βιοδεικτών και νέων θεραπευτικών στόχων έχει ιδιαίτερο ερευνητικό ενδιαφέρον. Το ΗΚΚ αναπτύσσεται συνήθως σε έδαφος ηπατίτιδας και κίρρωσης, που έχουν ως αποτέλεσμα την χρόνια φλεγμονή του παρεγχύματος και βλάβη του ηπατοκυττάρου. Σε μοριακό επίπεδο, οι βλάβες του DNA, οι γενετικές αλλαγές και η αστάθεια του γονιδιώματος αποτελούν κοινά χαρακτηριστικά της νόσου. Όπως σε όλες τις νεοπλασίες, έτσι και στο ΗΚΚ, κατά την κακοήθη εξαλλαγή τα καρκινικά κύττταρα αποκτούν ορισμένα ιδιαίτερα χαρακτηριστικά όπως ο ανεξέλεγκτος κυτταρικός πολλαπλασιασμός, η αποφυγή της απόπτωσης, η ικανότητα διήθησης και μετάστασης και η αγγειογένεση. Η αστάθεια του γονιδιώματος, που χαρακτηρίζεται από συσσώρευση μεταλλάξεων και χρωμοσωμικών ανωμαλιών, αποτελεί έναν από τους σημαντικότερους μηχανισμούς ανάπτυξης και εξέλιξης του καρκίνου, καθώς διευκολύνει την απόκτηση όλων των κύριων χαρακτηριστικών των καρκινικών κυττάρων. Ιδιαίτερα, βλάβες στο DNA λόγω αντιγραφικού στρες που ενεργοποιούν μηχανισμούς απόκρισης στην βλαβη του DNA (DDR) παρουσιάζονται αρκετά νωρίς στην καρκινογένεση. Πολύ σημαντικό ρόλο στον έλεγχο του κυτταρικού πολλαπλασιασμού και στην διατήρηση της ακεραιότητας του γονιδιώματος διαδραματίζουν οι μηχανισμοί ελέγχου του κυτταρικού κύκλου. Σημαντικός μηχανισμός ελέγχου του κυτταρικού κύκλου αποτελεί η αδειοδότηση της αντιγραφής του DNA. Οι παράγοντες αδειοδότησης αποτελούν όχι μόνο δείκτες κυτταρικού πολλαπλασιασμού, αλλά παίζουν σημαντικό ρόλο στην διατήρηση της ακεραιότητας του γονιδιώματος, καθώς αποτρέπουν την υπερ- η υπο-αντιγραφή του DNA η οποία μπορεί να οδηγήσει σε αντιγραφικό στρες και γενετική αστάθεια. Επιπλέον, το σύμπλεγμα IPP (ILK-parvin-PINCH) εντοπιζόμενο στις εστιακές συνδέσεις, παίζει σημαντικό ρόλο στην καρκινογένεση καθώς μεταβιβάζει σήματα από την εξωκυττάρια ουσία και αυξητικούς παράγοντες ελέγχοντας σημαντικές λειτουργίες όπως η διήθηση και η μετάσταση, ο κυτταρικός πολλαπλασιασμός και η αγγειογένεση.Με βάση τα παραπάνω η παρούσα διατριβή επικεντρώθηκε στην μελέτη της έκφρασης δεικτών του κυτταρικού κύκλου καθώς και αγγειογενετικών παραγόντων στο ηπατοκυτταρικό καρκίνωμα. Συγκεκριμένα, για το σκοπό αυτό μελετήσαμε σε 111 ιστικά δείγματα ηπατοκυτταρικών καρκινωμάτων την έκφραση των παραγόντων αδειοδότησης της αντιγραφής του DNA Cdt1 και Mcm7, ρυθμιστών του κυτταρικού κύκλου, την έκφραση των παραγόντων p-H2AX, phospho-ATM/ATR και p53, δεικτών της απόκρισης της βλάβης του DNA, την έκφραση του αγγειογενετικού παράγοντα VEGF-A και του δείκτη αγγειογένεσης CD31 και την έκφραση των συστατικών του συμπλέγματος ΙΡP (ΙLK, β-parvin και PINCH), που εμπλέκονται στον έλεγχο του κυτταρικού πολλαπλασιασμού και της αγγειογένεσης. Παράλληλα, διερευνήσαμε την προγνωστική σημασία αυτών των παραγόντων αναλύοντας την σχέση τους με κλινικοπαθολογοανατομικές προγνωστικές παραμέτρους της νόσου και την επιβίωση των ασθενών.Συμπερασματικά αναδείξαμε πως ο παράγοντας αδειοδότησης Cdt1 εμφανίζει μεγαλύτερη ανοσοϊστοχημική έκφραση στο ΗΚΚ σε σχέση με το παρακείμενο μη νεοπλασματικό ηπατικό παρέγχυμα, σχετίζεται με το βαθμό διαφοροποίησης των όγκων και το στάδιο της νόσου και σχετίζεται στατιστικώς σημαντικά με χαμηλή επιβίωση των ασθενών με ΗΚΚ (p=0.049). Επιπλέον, δείξαμε πως ο παράγοντας αδειοδότησης Mcm7 εμφανίζει μεγαλύτερη ανοσοϊστοχημική έκφραση στο ΗΚΚ, αλλά δεν σχετίζεται με τους κλινικοπαθολογοανατομικούς δείκτες της νόσου και την επιβίωση των ασθενών με ΗΚΚ. Ιδιαίτερα ενδιαφέρον εύρημα της μελέτης μας ήταν ότι οι δείκτες απόκρισης της βλάβης του DNA p-H2AX, phospho-ATM/ATR και p53 εμφανίζουν μεγαλύτερη ανοσοϊστοχημική έκφραση στο ΗΚΚ και σχετίζονται με τους παράγοντες αδειοδότησης Cdt1 και Mcm7.Παράλληλα, επιβεβαιώσαμε πως η ILK υπερεκφράζεται στα ΗΚΚ και σχετίζεται με τους ρυθμιστές αδειοδότησης, τους δείκτες απόκρισης στην βλάβη του DNA (DDRs) και την αγγειογένεση, ενώ οι πρωτεΐνες β-parvin και PINCH υπερεκφράζονται στο ΗΚΚ.Επιπλέον, δείξαμε πως ο αγγειακός ενδοθηλιακός αυξητικός παράγοντας VEGF-A εμφανίζει μεγαλύτερη ανοσοϊστοχημική έκφραση στον ηπατοκυτταρικό καρκίνο και σχετίζεται με χαμηλή επιβίωση στους ασθενείς με ηπατίτιδα Β. Τέλος, δείξαμε ότι η αγγειακή πυκνότητα (vascular density) με βάση τον ενδοθηλιακό δείκτη CD31 σχετίζεται με την παρουσία αγγειακής διήθησης στον ΗΚΚ.Αν και χρειάζονται περαιτέρω μελέτες για την επιβεβαίωση των σχέσεων που αναδείξαμε στην παρούσα μελέτη, τα δεδομένα μας συμπληρώνουν τις ως τώρα γνώσεις για την ανάπτυξη του ΗΚΚ και ανοίγουν νέους ορίζοντες στην καλύτερη κατανόηση της παθογένειας του ΗΚΚ και στην έρευνα νέων θεραπειών

Management of infected post-pancreatic resection fluid collections under endoscopic ultrasound guidance using lumen apposing metal stent: a case series and review of the literature

Backgrounds/Aims: Post-operative pancreatic fistulas (POPF) and fluid collections (POPFC) remain significant sources of morbidity and mortality after pancreatic resections. There remains a paucity of literature describing endoscopic ultrasound (EUS) guided drainage of POPFC using a Hot AXIOS™ lumen apposing metal stent (LAMS).Methods: We conducted a retrospective study, encompassing all consecutive patients with POPFC managed using Hot AXIOS™ LAMS at our institution between January 2017 and December 2019. Primary outcome measures were technical and clinical success. Secondary outcome measures were adverse events and recurrence rates.Results: Five patients underwent EUS guided drainage using Hot AXIOS™ LAMS during the study period. Mean age of patients was 67.8 ± 2.16 years. The majority (60.0%) of patients were males. Median duration of symptom onset after surgery was 9 days. All patients presented with abdominal pain. Median size of the collection measured on computed tomography was 91 mm. Median interval time between symptom onset and EUS drainage was 30 days. Two patients required percutaneous drainage prior to EUS guided drainage. Technical and clinical success were achieved for all patients. No adverse events were observed. Median duration of follow-up was 90 days. No recurrence of collection occurred during the follow-up period.CConclusions: EUS guided drainage of POPFC using Hot AXIOS™ LAMS is a safe and effective treatment modality with technical and clinical success rates of 100% in our experience

Liver resection for metastatic uveal melanoma: experience from a supra-regional centre and review of literature

Management of liver metastases from uveal melanoma (LMUM) requires multimodal approach. This study describes evolution of liver resection for LMUM, reviewing current literature and institutional outcomes. Records of patients referred to the Melanoma Multi-Disciplinary Team between February 2005 and August 2018 were reviewed. All publications describing surgery for LMUM were identified from PubMed, Embase, and Google Scholar. Thirty-one of 147 patients with LMUM underwent laparoscopic liver biopsy, and 29 (14 females) had liver resections. Nineteen liver resections were performed locally [7 major (≥3 seg), 14 laparoscopic] without major complications or mortality. Overall survival positively correlated with the time from uveal melanoma to LMUM (Spearman's rho rs  = 0.859, P  &lt; 0.0001). Overall and recurrence-free survivals were comparable following R1 or R0 resections (OS 25 vs. 28 months, P  = 0.404; RFS 13 vs. 6 months, P  = 0.596). R1 resection cohort had longer lead-time (median 100 vs. 24 months, P  = 0.0408). Eleven publications describing liver resection for LMUM were identified and included in the narrative review. Surgery for LMUM is safe and complements multidisciplinary management. Despite heterogeneity in literature, time from diagnosis of uveal melanoma to LMUM remains a key factor affecting survival after liver resection.</p

Adjuvant chemotherapy for adenocarcinoma arising from intraductal papillary mucinous neoplasia: multicentre ADENO-IPMN study

Background: The clinical impact of adjuvant chemotherapy after resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia is unclear. The aim of this study was to identify factors related to receipt of adjuvant chemotherapy and its impact on recurrence and survival. Methods: This was a multicentre retrospective study of patients undergoing pancreatic resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia between January 2010 and December 2020 at 18 centres. Recurrence and survival outcomes for patients who did and did not receive adjuvant chemotherapy were compared using propensity score matching. Results: Of 459 patients who underwent pancreatic resection, 275 (59.9%) received adjuvant chemotherapy (gemcitabine 51.3%, gemcitabine–capecitabine 21.8%, FOLFIRINOX 8.0%, other 18.9%). Median follow-up was 78 months. The overall recurrence rate was 45.5% and the median time to recurrence was 33 months. In univariable analysis in the matched cohort, adjuvant chemotherapy was not associated with reduced overall (P = 0.713), locoregional (P = 0.283) or systemic (P = 0.592) recurrence, disease-free survival (P = 0.284) or overall survival (P = 0.455). Adjuvant chemotherapy was not associated with reduced site-specific recurrence. In multivariable analysis, there was no association between adjuvant chemotherapy and overall recurrence (HR 0.89, 95% c.i. 0.57 to 1.40), disease-free survival (HR 0.86, 0.59 to 1.30) or overall survival (HR 0.77, 0.50 to 1.20). Adjuvant chemotherapy was not associated with reduced recurrence in any high-risk subgroup (for example, lymph node-positive, higher AJCC stage, poor differentiation). No particular chemotherapy regimen resulted in superior outcomes. Conclusion: Chemotherapy following resection of adenocarcinoma arising from intraductal papillary mucinous neoplasia does not appear to influence recurrence rates, recurrence patterns or survival

Risk of recurrence after surgical resection for adenocarcinoma arising from intraductal papillary mucinous neoplasia (IPMN) with patterns of distribution and treatment

Objective: This international multicentre cohort study aims to identify recurrence patterns and treatment of first and second recurrence in a large cohort of patients after pancreatic resection for adenocarcinoma arising from IPMN. Summary Background Data: Recurrence patterns and treatment of recurrence post resection of adenocarcinoma arising from IPMN are poorly explored. Method: Patients undergoing pancreatic resection for adenocarcinoma from IPMN between January 2010 to December 2020 at 18 pancreatic centres were identified. Survival analysis was performed by the Kaplan-Meier log rank test and multivariable logistic regression by Cox-Proportional Hazards modelling. Endpoints were recurrence (time-to, location, and pattern of recurrence) and survival (overall survival and adjusted for treatment provided). Results: Four hundred and fifty-nine patients were included (median, 70 y; IQR, 64-76; male, 54 percent) with a median follow-up of 26.3 months (IQR, 13.0-48.1 mo). Recurrence occurred in 209 patients (45.5 percent; median time to recurrence, 32.8 months, early recurrence [within 1 y], 23.2 percent). Eighty-three (18.1 percent) patients experienced a local regional recurrence and 164 (35.7 percent) patients experienced distant recurrence. Adjuvant chemotherapy was not associated with reduction in recurrence (HR 1.09;P=0.669) One hundred and twenty patients with recurrence received further treatment. The median survival with and without additional treatment was 27.0 and 14.6 months (P&lt;0.001), with no significant difference between treatment modalities. There was no significant difference in survival between location of recurrence (P=0.401). Conclusion: Recurrence after pancreatic resection for adenocarcinoma arising from IPMN is frequent with a quarter of patients recurring within 12 months. Treatment of recurrence is associated with improved overall survival and should be considered

Long-term outcomes following resection of Adenocarcinoma arising from Intraductal Papillary Mucinous Neoplasm (A-IPMN) versus Pancreatic Ductal Adenocarcinoma (PDAC): a propensity-score matched analysis

Objective: The aim of the present study was to compare long-term post-resection oncological outcomes between A-IPMN and PDAC. Summary Background Data: Knowledge of long term oncological outcomes (e.g recurrence and survival data) comparing between adenocarcinoma arising from intraductal papillary mucinous neoplasms (A-IPMN) and pancreatic ductal adenocarcinoma (PDAC) is scarce. Methods: Patients undergoing pancreatic resection (2010-2020) for A-IPMN were identified retrospectively from 18 academic pancreatic centres and compared with PDAC patients from the same time-period. Propensity-score matching (PSM) was performed and survival and recurrence were compared between A-IPMN and PDAC. Results: 459 A-IPMN patients (median age,70; M:F,250:209) were compared with 476 PDAC patients (median age,69; M:F,262:214). A-IPMN patients had lower T-stage, lymphovascular invasion (51.4%vs. 75.6%), perineural invasion (55.8%vs. 71.2%), lymph node positivity (47.3vs. 72.3%) and R1 resection (38.6%vs. 56.3%) compared to PDAC(P&lt;0.001). The median survival and time-to-recurrence for A-IPMN versus PDAC were 39.0 versus19.5months (P&lt;0.001) and 33.1 versus 14.8months (P&lt;0.001), respectively (median follow-up,78 vs.73 months). Ten-year overall survival for A-IPMN was 34.6%(27/78) and PDAC was 9%(6/67). A-IPMN had higher rates of peritoneal (23.0 vs. 9.1%, P&lt;0.001) and lung recurrence (27.8% vs. 15.6%, P&lt;0.001) but lower rates of locoregional recurrence (39.7% vs. 57.8%; P&lt;0.001). Matched analysis demonstrated inferior overall survival (P=0.005), inferior disease-free survival (P=0.003) and higher locoregional recurrence (P&lt;0.001) in PDAC compared to A-IPMN but no significant difference in systemic recurrence rates (P=0.695). Conclusions: PDACs have inferior survival and higher recurrence rates compared to A-IPMN in matched cohorts. Locoregional recurrence is higher in PDAC but systemic recurrence rates are comparable and constituted by their own distinctive site-specific recurrence patterns