Annals of Surgery

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Telemedicine for Surgical Consultations – Pandemic Response or Here to Stay?: A Report of Public Perceptions

imageObjective:
This study aims to determine the public's perception of telemedicine surgical consultations, during the COVID-19 pandemic and beyond.
Summary Background Data:
With rapid expansion and uptake of telemedicine during the pandemic, many have posited that virtual visits will endure even as in-person visits are reinstated. The public's perception of telemedicine for an initial surgical consultation has not been previously studied.
Methods:
A 43-question survey assessed respondents’ attitudes toward telemedicine for initial consultations with surgeons, both in the context of COVID-19 and during “normal circumstances.” Participants were recruited through Amazon Mechanical Turk, an online crowd-sourcing marketplace.
Results:
Based on 1827 analyzable responses, we found that a majority (86%) of respondents reported being satisfied (either extremely or somewhat) with telemedicine encounters. Interestingly, preference for in-person versus virtual surgical consultation reflected access to care, with preference for telemedicine decreasing from 72% to 33% when COVID-related social distancing ends. Preferences for virtual visits decreased with increasing complexity of the surgical intervention, even during the pandemic. A majority felt that “establishing trust and comfort” was best accomplished in person, and the vast majority felt it was important to meet their surgeons before the day of surgery.
Conclusions:
The public views telemedicine as an acceptable substitute for in-person visits, especially during the pandemic. However, it seems that an in-person interaction is still preferred when possible for surgical consultations. If telemedicine services are to persist beyond social distancing, further exploration of its impact on the patient-surgeon relationship will be needed.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/Telemedicine_for_Surgical_Consultations___Pandemic.35.aspx

Outcomes After Tracheostomy in COVID-19 Patients

imageObjective:
To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures.
Background:
Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure.
Methods:
A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19.
Results:
Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ± 6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ± 6.9 days (range 2–32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure.
Conclusions:
Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/Outcomes_After_Tracheostomy_in_COVID_19_Patients.36.aspx

Significance of Lymph Node Resection After Neoadjuvant Therapy in Pancreatic, Gastric, and Rectal Cancers

imageObjective:
Gastrointestinal cancers are increasingly being treated with NAT before surgical resection. Currently, quality metrics are linked to the number of LNs resected to determine subsequent treatment and prognosis. We hypothesize that NAT decreases LN metastasis, downstages patients, and decreases overall lymph node yields (LNY) compared to initial surgical resection. With increasing use of NAT, this brings into question the validity of quality metrics.
Methods:
Gastric (stage II/III), pancreatic (stage I/II/III), and rectal cancers (stage II/III) (2010–2015) treated with surgery with/without NAT were identified in National Cancer Database. We evaluated total LNY and LN metastasis with/without NAT and clinical and pathological stage to evaluate rates of downstaging.
Results: :
A total of 7934 gastric, 15,908 pancreatic, and 21,354 rectal cancer patients were included of which 61.1%, 21.2%, and 85.7% received NAT, respectively. NAT patients were more likely to be downstaged (39.9% vs 11.1% gastric P< 0.001, 30.6% vs 3.2% pancreatic P< 0.001, 52.0% vs 16.3% rectal P< 0.001), have lower LNYs (18.8 vs 19.1 gastric P = 0.239, 18.4 vs 17.5 pancreatic P< 0.001, 15.7 vs 20.0 rectal P< 0.001) and have N0 pathologic disease (43.6% vs 26.7% gastric P< 0.001, 51.1% vs 30.9% pancreatic P< 0.001, 65.9% vs 49.4% rectal P< 0.001) when compared to initial surgical resection.
Conclusion:
NAT for gastrointestinal cancers results in overall lower LN yields, lower LN metastases, and significant downstaging of tumors. As all patients undergoing NAT receive multimodality therapy, LN yield recommendations may not be true quality metric changing.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/Significance_of_Lymph_Node_Resection_After.13.aspx

SARS-CoV-2 Is Present in Peritoneal Fluid in COVID-19 Patients

imageBackground:
The excretion pathomechanisms of SARS-CoV-2 are actually unknown. No certain data exist about viral load in the different body compartments and fluids during the different disease phases.
Material and Methods:
Specific real-time reverse transcriptase–polymerase chain reaction targeting 3 SARS-CoV-e genes were used to detect the presence of the virus.
Results:
SARS-CoV-2 was detected in peritoneal fluid at a higher concentration than in respiratory tract.
Conclusion:
Detection of SARS-CoV-2 in peritoneal fluid has never been reported. The present article represents the very first positive result describing the presence of the virus in peritoneal fluid during an emergency surgical procedure in a COVID-19 sick patient. This article thus represents a warning for increasing the level of awareness and protection for surgeon especially in emergency surgical setting.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/SARS_CoV_2_Is_Present_in_Peritoneal_Fluid_in.53.aspx

Is It Safe to Manage Acute Cholecystitis Nonoperatively During Pregnancy?: A Nationwide Analysis of Morbidity According to Management Strategy

imageObjectives:
To compare CCY and nonoperative treatment (no-CCY) for acute cholecystitis in pregnancy.
Summary of Background Data:
Current Society of Gastrointestinal and Endoscopic Surgery guidelines recommend CCY over nonoperative management of acute cholecystitis during pregnancy, and the American College of Obstetricians and Gynecologists recommend medically necessary surgery regardless of trimester. This approach has been recently questioned.
Methods:
Pregnant women admitted with acute cholecystitis were identified using the Nationwide Readmission Database 2010–2015. Propensity score-adjusted logistic regression models we used to compare CCY and no-CCY. The primary outcome was a composite measure of adverse maternal-fetal outcomes (intrauterine death/stillbirth, poor fetal growth, abortion, preterm delivery, C-section, obstetric bleeding, infection of the amniotic fluid, venous thromboembolism).
Results:
There were 6390 pregnant women with acute cholecystitis: 38.2% underwent CCY, of which 5.1% were open. Patients were more likely to be managed operatively in their second trimester (20.7% vs 8.8%; P < 0.01). Patients managed with CCY did not differ in age, insurance, income, Charlson Comorbidity Index, diabetes or obesity when compared to no-CCY (all P > 0.05), but were less likely to have a previous C-section, gestational diabetes, preeclampsia/eclampsia or be in the third trimester (P ≤ 0.01). Risk-adjusted analyses showed that no-CCY was associated with significantly increased maternal-fetal complications during the index admission [odds ratio 3.0 (95% confidence interval 2.08–4.34), P < 0.01] and 30-day readmissions [odds ratio 1.61 (confidence interval % CI 1.12–2.32), P < 0.01].
Conclusions:
Contrary to current guidelines, most pregnant women admitted in the US with acute cholecystitis are managed nonoperatively. This is associated with over twice the odds of maternal-fetal complications in addition to increased readmissions.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/Is_It_Safe_to_Manage_Acute_Cholecystitis.15.aspx

I Can’t Breathe – Race, Violence, and COVID-19

No abstract available

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/I_Can_t_Breathe___Race,_Violence,_and_COVID_19.38.aspx

Electrocautery, Diathermy, and Surgical Energy Devices: Are Surgical Teams at Risk During the COVID-19 Pandemic?

imageObjective:
The aim of the study was to provide a rapid synthesis of available data to identify the risk posed by utilizing surgical energy devices intraoperatively due to the generation of surgical smoke, an aerosol. Secondarily it aims to summarize methods to minimize potential risk to operating room staff.
Summary Background Data:
Continuing operative practice during the coronavirus disease-19 (COVID-19) pandemic places the health of operating theatre staff at potential risk. SARS-CoV2 is transmitted through inhaled droplets and aerosol particles, thus posing an inhalation threat even at considerable distance. Surgical energy devices generate an aerosol of biological particular matter during use. The risk to healthcare staff through use of surgical energy devices is unknown.
Methods:
This review was conducted utilizing a rapid review methodology to enable efficient generation and dissemination of information useful for concurrent clinical practice.
Results:
There are conflicting stances on the use of energy devices and laparoscopy by different surgical governing bodies and societies. There is no definitive evidence that aerosol generated by energy devices may carry active SARS-CoV2 virus. However, investigations of other viruses have demonstrated aerosolization through energy devise use. Measures to reduce potential transmission include appropriate personal protective equipment, evacuation and filtration of surgical plume, limiting energy device use if appropriate, and adjusting endoscopic and laparoscopic practice (low CO2 pressures, evacuation through ultrafiltration systems).
Conclusions:
The risk of transmission of SARS-CoV2 through aerosolized surgical smoke associated with energy device use is not fully understood, however transmission is biologically plausible. Caution and appropriate measures to reduce risk to healthcare staff should be implemented when considering intraoperative use of energy devices.

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https://journals.lww.com/annalsofsurgery/Fulltext/2020/09000/Electrocautery,_Diathermy,_and_Surgical_Energy.59.aspx

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