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

A 12-year old with a duodenal bulb perforation

Case description: A 12-year old girl was hospitalized in a peripheral hospital. She had been suffering from muscle pains and edema for over a month, that had started after an episode of fever and throat pain. At admission, the diagnosis of viral myositis was made. She was transferred to the pediatric intensive care unit of Ghent University Hospital. Juvenile dermatomyositis was suspected, and high dose corticosteroids were initiated. A week after admission, she developed abdominal pain and distension combined with respiratory deterioration. RX thorax showed a significant amount of intraperitoneal air, so a CT abdomen was performed. This showed significant free air and fluid, caused by an intestinal perforation. Exploratory laparoscopy revealed a large perforation of the duodenum which was sutured laparoscopically and combined with an omentoplasty. A week after surgery, a fall in hemoglobin level from 8.1 to 5.0 g/dL was noticed. Moreover, blood was aspirated from the nasogastric tube and melena was present. Gastroscopy confirmed a large duodenal ulcer that was treated with gel application. Control gastroscopies in the week afterwards showed positive evolution of the ulcer. However, two days after the third gastroscopy, her abdomen started to become tender and distended. Gastroscopy and CT scan revealed a recurrence of the duodenal bulb perforation. An exploratory laparotomy was performed. This revealed a contaminated abdomen with biliary peritonitis. A perforation at the earlier suture was identified, but it had become more of a laceration and extended into the descending part of the duodenum. A Billroth 2 resection was deemed unfeasible, so a Whipple resection was performed. No reconstructions were made immediately and both pancreas and biliary tract were derived externally. Anastomoses could be performed two days later. The patient was weaned from sedation and ventilation two weeks later. Peroral feeding was initiated a month after surgery. She was transferred to a regular pediatric unit two months after initial admission and is currently doing well. Conclusion: Juvenile dermatomyositis with gastrointestinal perforation is extremely rare and lethal according to literature. We present a case in which aggressive surgery lead to survival of the patient

Early postoperative systemic inflammatory response as predictor of anastomotic leakage after esophagectomy : a systematic review and meta-analysis

Background and purpose Postesophagectomy anastomotic leakage occurs in up to 16% of patients and is the main cause of morbidity and mortality. The leak severity is determined by the extent of contamination and the degree of sepsis, both of which are related to the time from onset to treatment. Early prediction based on inflammatory biomarkers such as C-reactive protein (CRP) levels, white blood cell counts, albumin levels, and combined Noble-Underwood (NUn) scores can guide early management. This review aimed to determine the diagnostic accuracy of these biomarkers. Methods This study was designed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered in the PROSPERO (International Prospective Register of Systematic Reviews) database. Two reviewers independently conducted searches across PubMed, MEDLINE, Web of Science, and Embase. Sources of bias were assessed, and a meta-analysis was performed. Results Data from 5348 patients were analyzed, and 13% experienced leakage. The diagnostic accuracy of the serum biomarkers was analyzed, and pooled cutoff values were identified. CRP levels were found to have good diagnostic accuracy on days 2 to 5. The best discrimination was identified on day 2 for a cutoff value 10 on day 4 correlated with poor diagnostic accuracy. Conclusion The NUn score failed to achieve adequate accuracy. CRP seems to be the only valuable biomarker and is a negative predictor of postesophagectomy leakage. Patients with a CRP concentration of <222 mg/L on day 2 are unlikely to develop a leak, and patients can safely proceed through their enhanced recovery after surgery protocol. Patients with a CRP concentration of <127 mg/L on day 5 can be safely discharged when clinically possible

A 12-year old with a duodenal bulb perforation

Introduction: Juvenile dermatomyositis(JDM) is a rare pediatric disease, that might affect several systems throughout the body. Gastro-intestinal (GI) perforation is a rare complication of the disease, that has high mortality rates according to literature. We encountered a case of JDM-associated GI perforation in our center, that was eventually treated with a Whipple procedure. Case description : A 12-year old girl was hospitalized in a peripheral hospital. She had been suffering from muscle pains and edema for over a month, that had started after an episode of fever and throat pain. At admission, the diagnosis of viral myositis was made. She was transferred to the pediatric intensive care unit of Ghent University Hospital. Juvenile dermatomyositis was suspected, and high dose corticosteroids were initiated. A week after admission, she developed abdominal pain and distension combined with respiratory deterioration. RX thorax showed a significant amount of intraperitoneal air, so a CT abdomen was performed. This showed significant free air and fluid, caused by an intestinal perforation. Exploratory laparoscopy revealed a large perforation of the duodenum which was sutured laparoscopically and combined with an omentoplasty. A week after surgery, a fall in hemoglobin level from 8.1 to 5.0 g/dL was noticed. Moreover, blood was aspirated from the nasogastric tube and melena was present. Gastroscopy confirmed a large duodenal ulcer that was treated with gel application. Control gastroscopies in the week afterwards showed positive evolution of the ulcer. However, two days after the third gastroscopy, her abdomen started to become tender and distended. Gastroscopy and CT scan revealed a recurrence of the duodenal bulb perforation. An exploratory laparotomy was performed. This revealed a contaminated abdomen with biliary peritonitis. A perforation at the earlier suture was identified, but it had become more of a laceration and extended into the descending part of the duodenum. A Billroth 2 resection was deemed unfeasible, so a Whipple resection was performed. No reconstructions were made immediately and both pancreas and biliary tract were derived externally. Anastomoses could be performed two days later. Results: The patient was weaned from sedation and ventilation two weeks later. Peroral feeding was initiated a month after surgery. She was transferred to a regular pediatric unit two months after initial admission and went home six weeks later. Conclusion: Juvenile dermatomyositis with gastrointestinal perforation is extremely rare and lethal according to literature. We present a case in which aggressive surgery lead to survival of the patient

Clinical utility of near‑infrared perfusion assessment of the gastric tube during Ivor Lewis esophagectomy

Background Anastomotic leakage (AL) after Ivor Lewis esophagectomy with intrathoracic anastomosis carries a significant morbidity. Adequate perfusion of the gastric tube (GT) is an important predictor of anastomotic integrity. Recently, near infrared fluorescent (NIRF) imaging using indocyanine green (ICG) was introduced in clinical practice to evaluate tissue perfusion. We evaluated the feasibility and efficacy of GT indocyanine green angiography (ICGA) after Ivor Lewis esophagectomy. Methods This retrospective analysis used data from a prospectively kept database of consecutive patients who underwent Ivor Lewis (IL) esophagectomy with GT construction for cancer between January 2016 and December 2020. Relevant outcomes were feasibility, ICGA complications and the impact of ICGA on AL. Results 266 consecutive IL patients were identified who matched the inclusion criteria. The 115 patients operated with perioperative ICGA were compared to a control group in whom surgery was performed according to the standard of care. ICGA perfusion assessment was feasible and safe in all 115 procedures and suggested a poorly perfused tip in 56/115 (48.7%) cases, for which additional resection was performed. The overall AL rate was 16% (43/266), with 12% (33/266) needing an endoscopic our surgical intervention and 6% (17/266) needing ICU support. In univariable and multivariable analyses, ICGA was not correlated with the risk of AL (ICGA:14.8% vs non-ICGA:17.2%, p = 0.62). However, poor ICGA perfusion of the GT predicted a higher AL rate, despite additional resection of the tip (ICGA poorly perfused: 19.6% vs ICG well perfused: 10.2%, p = 0.19). Conclusions ICGA is safe and feasible, but did not result in a reduction of AL. The interpretation and necessary action in case of perioperative presence of ischemia on ICGA have yet to be determined. Prospective randomized trials are warranted to analyze its benefit on AL in esophageal surgery. Trial registration Ethical approval for a prospective esophageal surgery database was granted by the Ethical committee of the Ghent University Hospital. Belgian registration number: B670201111232. Ethical approval for this retrospective data analysis was granted by our institutional EC. Registration number: BC-09216

Systemic inflammatory response and the noble and underwood (NUn) score as early predictors of anastomotic leakage after esophageal reconstructive surgery

Anastomotic leakage (AL) remains the main cause of post-esophagectomy morbidity and mortality. Early detection can avoid sepsis and reduce morbidity and mortality. This study evaluates the diagnostic accuracy of the Nun score and its components as early detectors of AL. This single-center observational cohort study included all esophagectomies from 2010 to 2020. C-reactive protein (CRP), albumin (Alb), and white cell count (WCC) were analyzed and NUn scores were calculated. The area under the curve statistic (AUC) was used to assess their predictive accuracy. A total of 74 of the 668 patients (11%) developed an AL. CRP and the NUn-score proved to be good diagnostic accuracy tests on postoperative day (POD) 2 (CRP AUC: 0.859; NUn score AUC: 0.869) and POD 4 (CRP AUC: 0.924; NUn score AUC: 0.948). A 182 mg/L CRP cut-off on POD 4 yielded a 87% sensitivity, 88% specificity, a negative predictive value (NPV) of 98%, and a positive predictive value (PPV) of 47.7%. A NUn score cut-off > 10 resulted in 92% sensitivity, 95% specificity, 99% NPV, and 68% PPV. Albumin and WCC have limited value in the detection of post-esophagectomy AL. Elevated CRP and a high NUn score on POD 4 provide high accuracy in predicting AL after esophageal cancer surgery. Their high negative predictive value allows to select patients who can safely proceed with enhanced recovery protocols

Long-term results of a prospective study on laparoscopic adjustable gastric banding for morbid obesity

Objective To study the long-term outcome of adjustable gastric banding in the treatment for morbid obesity. Summary background In Europe, the preference for the gastric band has declined in favor of the Roux-Y gastric bypass (RYGB). Methods Follow-up of a prospective study on a large cohort of patients after laparoscopic gastric banding (LAGB) for morbid obesity. Results Complete data were collected on 656 patients (88%) from a cohort of 745 patients. After a median follow-up of 95 months (range 60-155) the mean BMI dropped from 41.0 ± 7.3 kg/m2 to 33.2 ± 7.1 kg/m2, with a 46.2 ± 36.5% excess weight loss (EWL). A more than 50% EWL was achieved in 44% of patients. The band was still in place in 77.1% of patients, and conversion to gastric bypass after band removal was carried out in 98 (14.9%) patients, while a simple removal was done in only 52 (7.9%) patients. Band removal was more likely in women and patients with a higher BMI. Conclusions After LAGB, band removal was necessary for complications or insufficient weight loss in 24% of patients. Nearly half of the patients achieved a more than 50% EWL but in 88% a more than 10% EWL was observed. LAGB can achieve an acceptable weight loss in some patients, but the failure in one out of four patients does not allow to propose it as a first line option for the treatment of obesity

Assessing chest tube insertion skills using a porcine rib model : a validity study

Introduction Assessments require sufficient validity evidence before their use. The Assessment for Competence in Chest Tube Insertion (ACTION) tool evaluates proficiency in chest tube insertion (CTI), combining a rating scale and an error checklist. The aim of this study was to collect validity evidence for the ACTION tool on a porcine rib model according to the Messick framework. Methods A rib model, consisting of a porcine hemithorax that was placed in a wooden frame, was used as simulator. Participants were recruited from the departments of surgery, pulmonology, and emergency medicine. After familiarization with the rib model and the equipment, standardized instructions and clinical context were provided. They performed 2 CTIs while being scored with the ACTION tool. All performances were assessed live by 1 rater and by 3 blinded raters using video recordings. Generalizability-analysis was performed and mean scores and errors of both groups on the first performance were compared. A pass/fail score was established using the contrasting groups' method. Results Nine novice and 8 experienced participants completed the study. Generalizability coefficients where high for the rating scale (0.92) and the error checklist (0.87). In the first CTI, novices scored lower than the experienced group (38.1/68 vs. 47.1/68, P = 0.042), but no difference was observed on the error checklist. A pass/fail score of 44/68 was established. Conclusion A solid validity argument for the ACTION tool's rating scale on a porcine rib model is presented, allowing formative and summative assessment of procedural skills during training before patient contact