Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Right hepatic artery pseudoaneurysm as complication of laparoscopic cholecystectomy

Laparoscopic cholecystectomy complications include rare and fatal complication named hepatic artery pseudoaneurysm (HAPA). It is always iatrogenic. Mortality rates of about 50% of patients have been reported if rupture occurs. This report presents a case of a 42-year-old woman with history of laparoscopic cholecystectomy 6 months before. She has had few attacks of hematemesis; the last was one week prior to imaging. Multislice CT angiography (MSCTA) for the celiac trunk and CT portography (MSCTP) for portal venous system was requested aiming to locate the site of the bleeding

Ileal Crohn's disease activity predicted by ruler: CT enterography histopathology correlation

Objective: The aim of this study was to explore the predictive value of CT enterography-based simple measurement tools for Crohn's disease activity. Patients and methods: During one and half year duration 54 patients diagnosed with CD were retrospectively evaluated. All patients underwent CT enterography examinations following a preset protocol prior to endoscopic biopsy or surgery. The images obtained were reconstructed using dedicated software and workstations. The length of affected segments was calculated (L) and distance from ileocecal junction till first affected segment was measured (D). Results of CTE examinations were compared with histopathology. Results: Out of 54 cases, 38 cases had single segment involvement (70.4%) and 16 cases had multiple affected segments (29.6%). The histological inflammatory activity score scored 1 in 10 cases (18.5%), 2 in 25 cases (46.3%) and 3 in 19 cases (35.2%). L varied from 1.4 cm to 20.6 cm while D varied from 0 to 6.7 cm. Spearman rank order correlation coefficient showed a strong uphill linear relationship of L (RHO = 0.663) and weak correlation of D (RHO = 0.222) with the histological inflammatory activity score. Conclusion: CTE provides accurate data regarding length of affected ileal segments that positively correlated with histopathological score of disease activity

Upper limb DVT after hemodialysis

Objective: The aim of this study was to assess the role of CT venography (CTV) in diagnosis of upper limb deep venous thrombosis (DVT) after arterio-venous fistula (AVF) creation for patients with chronic renal failure (CRF) under regular hemodialysis. Patients and methods: During two years duration 22 patients with upper limb hemodialysis arterio-venous fistulas suspected to have deep venous thrombosis were prospectively evaluated. All patients underwent CTV examinations following a preset protocol. The images obtained were reconstructed using dedicated software and workstations. Results of CTV examinations were compared with those of Color Doppler (CD) examinations. Results: Out of 22 examined cases, 20 cases (90.9%) had autogenous AVF and 2 cases (9.1%) had synthetic grafts. Diagnosis of proximal upper limb segment DVT including brachial, axillary and subclavian veins recorded 12 TP (54.5%), 8 TN (36.4%), 2 FP (9.1%) and no FN cases. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 100%, 80%, 85.7% and 100% respectively. Diagnosis of central venous segment DVT including innominate veins and SVC recorded 14 TP (63.6%), 8 TN (36.4%) and neither FP nor FN cases. Sensitivity, specificity, PPV and NPV were 100%, 100%, 100% and 100% respectively. Conclusion: CTV has a major role in diagnosis of deep venous thrombosis particularly the central innominate veins/SVC segment after upper limb AVF creation for patients with CRF under hemodialysis

Complicated IVC anomalies: Are they more common than we thought? An experience of 100 MDCT venography examinations

Objective: The aim of this study was to monitor the incidence of complicated inferior vena cava (IVC) anomalies and evaluate the role of Multidetector Computed Tomographic Venography (MDCTV) in diagnosis and assessment of associated venous collaterals, lower limb deep venous thrombosis (DVT) or varicose veins (VV). Patients and methods: During two years duration 100 patients with clinical history and complains suggesting of DVT or VV were prospectively evaluated after performance of MDCTV examination. The images obtained were interpreted and reconstructed using dedicated software and work stations. Results were correlated with Color Doppler Ultrasound (CDUS) findings. Results: Out of 100 cases, 9 cases (9%) were diagnosed to have complicated IVC anomalies while 91 cases (91%) had either well developed IVC or common anatomical variations. 6 cases (66.7%) had complicated IVC anomalies and 3 cases (33.3%) had associated complicated common iliac veins (CIV) anomalies. 8 cases (88.9%) had associated DVT and all cases (100%) had bilateral VV. 2 cases (22.2%) had associated varicocele and 1 case (11.1%) had associated KILT syndrome. Conclusion: MDCT venography examination has a major role in diagnosis of complicated IVC anomalies and detection of associated venous collaterals, lower limb DVT or VV

Large primary vaginal stone secondary to vesico-vaginal fistula in a 63-year-old woman

Vaginal stones are incredibly rare. Primary stones are seen in cases of urethro-vaginal or vesico-vaginal fistula. Secondary stones are more common and caused by deposition of calcium over foreign bodies introduced into the vagina. This report presents a case of a 63-year-old woman with vesico-vaginal fistula incidentally diagnosed to have large vaginal stone. The patient was referred to our practice suffering from urine dribbling through the vagina for a long time secondary to vesico-vaginal fistula. She has had repetitive unsuccessful attempts of surgical repair. MRI examination of the pelvis was requested aiming to locate the site of the fistula

Do we need 18F-FDG PET/CT sc

Objective: The aim of this study was to assess the role of positron emission tomography/computed tomography (PET/CT) scan in preoperative staging of testicular tumors and therefore determining the line of appropriate management. Patients and methods: During two year duration we prospectively evaluated 34 patients with testicular tumors diagnosed by histopathology after biopsy or orchidectomy. All patients underwent PET/CT examinations following a preset protocol that included low dose non contrast study, whole body scanning post 18F-FDG injection and post IV contrast CT scan. The images obtained were reconstructed using dedicated software and workstations. Results of PET/CT examinations were compared with histopathology and serum markers. Results: Out of 34 cases all masses were malignant (germ cell tumors). 20 masses (58.8%) were diagnosed by histopathology as seminoma subtype while 14 masses (41.2%) were diagnosed as non seminomatous germ cell tumors (NSGCT) subtype. There were 16 true positives, 14 true negatives, 2 false positive, and 2 false negative cases. Sensitivity, specificity, positive predictive value and negative predictive values were 88.9%, 87.5%, 88.9% and 87.5% respectively. Conclusion: Positron emission tomography/computed tomography (PET/CT) has a major role in preoperative staging of testicular tumors and defines the need of post operative adjuvant therapy

Follow up CT angiography post EVAR: Endoleaks detection, classification and management planning

Objective: The goal of this study was to highlight the role of follow up CT angiography examination in detection and classification of endoleaks and therefore deciding management plans after endovascular abdominal aortic aneurysm repair (EVAR). Patients and Methods: During one year duration 37 patients who have been operated were examined 1 and 6 months after EVAR as routine follow up. The images obtained were interpreted and reconstructed using dedicated software and work stations. Results: Out of 37 cases, 14 cases (37.8%) had positive endoleaks and 23 cases (62.2%) were free. Type I endoleak was diagnosed in 4 cases (10.8%) and type II endoleaks was diagnosed in 10 cases (27%) as 7 cases (18.9%) showed leak through lumbar arteries and 3 cases (8.1%) showed leak through the inferior mesenteric arteries. Conclusion: CT angiography can accurately detect and classify endoleaks and thus determine line of treatment. Endoleaks are often asymptomatic and may become evident intra operatively or many years after the operation, therefore lifelong imaging supervision is necessary. Keywords: CT angiography, EVAR, Endoleaks, Detection, Classificatio

Up and down staging of TCC using 18F-FDG PET/CT scan

Objective: The purpose of this study was to investigate the ability of PET/CT to restage urinary bladder transitional cell carcinoma (TCC) whether up or down after initial staging by histopathology and other imaging modalities. Patients and methods: During three year duration 27 patients with urinary bladder TCC were prospectively evaluated. They were previously diagnosed by histopathology after biopsy and had prior imaging for initial staging. All patients underwent PET/CT examinations following a preset protocol. The images obtained were reconstructed using dedicated software and workstations. Results of PET/CT examinations were confirmed by histopathology. Results: Prior imaging and PET/CT findings were matched in 17 patients (63%) with no changes regarding their initial TNM stages and differed in 10 patients (37%). Six patients (22.2%) showed new sites of distant metastasis and unchanged initial stages. Two patients (7.4%) were up staged and 2 patients (7.4%) were down staged for whom the plan of clinical management was justified. Conclusion: 18F-FDG PET/CT can up and down stage TCC and can detect new sites of nodal or distant metastasis leading to optimal therapy planning

Role of multiphasic multi-detector computed tomography (MDCT) in the diagnosis and staging of solid neoplastic renal masses

Objectives: The aim of this study was to assess the role of multi-detector computed tomography (MDCT) in diagnosis and preoperative staging of solid renal masses. Patients and methods: During two years duration we prospectively evaluated 56 patients with solid renal lesions previously detected by US. All patients underwent multiphasic CT scanning for the kidneys and urinary tract following a preset scanning protocol that included unenhanced, corticomedullary phase (CMP), nephrograhic phase (NP) and excretory phase (EP) scanning. The images obtained in the excretory delayed phase were reconstructed in different planes to obtain 2D and 3D reformatted images providing volume rendering VR and maximum intensity projection (MIP) CTU images. Curved reformatting was sometimes used for the ureter. The numbers of lesions detected in all three phases were determined. Results of CT scan were compared with histopathology or constellation of clinical and imaging patient data. Results: A total of 61 masses were detected in 56 cases, 51 cases had unilateral masses (91%), 5 cases had bilateral masses (9%). The different pathologies encountered in the study were RCC 39 masses (64%), Wilm’s tumor 3 masses (4.9%), transitional cell carcinoma 3 masses (4.9%), angiomyolipoma 7 masses (11.5%), lymphoma 6 masses (9.8%), metastasis one mass (1.6%), angiomyolipoma associated with RCC two masses (3.3%). Lymph nodal metastasis, renal vein, IVC thrombosis and distant metastatic spread in different pathologies were assessed. The attenuation HU values calculated in the early CMP for all cases of RCC had a mean value of 80.5 HU (STD 45.7) while the mean values in NP and EP were 70.6 HU (STD 25.4) and 51.3 HU (STD 19.2) respectively. A pattern of enhancement was detected in all cases of RCC in the form of rapid wash out of contrast and decrease of attenuation (HU) by time throughout different phases. Significant difference between HU in CMP and EP in cases of RCC (P value = 0.0002) and difference between HU in NP and EP in cases of RCC (P value < 0.00001) were found. Conclusion: Multiphase multislice computed tomography combined with CT angiography and CT urography have a major role in solid renal neoplastic masses’ diagnosis, characterization and differentiating benign and malignant tumors