We are excited to share a new section titled “Essential Articles for Surgical Residents.”
Keeping up with surgical literature in residency can be challenging. This list was created to serve as an easily accessible, up-to-date, and evidence-based resource for residents.
The content has been curated by faculty from each department and is intended to supplement the standard educational curriculum of each rotation with current and relevant literature.
Continue reading“Feeding jejunostomy is conventionally done via laparotomy. However, since laparoscopic jejunostomy was introduced in 1990, the procedure is constantly advancing with new techniques and devices. It was demonstrated to be a safe, feasible, and cost-effective technique with comparable complication rate to open feeding jejunostomy.”
“In addition, compared with the conventional open procedure, the laparoscopic approach has the inherit merits of smaller incisions, better cosmesis, less postoperative pain, and earlier recovery. With the aim of achieving early enteral feeding and a reduction in postoperative morbidity, any complications arising from the procedure will jeopardize its benefits, incur additional costs, and delay subsequent oncologic treatment.”
“Mechanical chest compression devices are designed to perform chest compressions at specified rate and depth and therefore were expected to improve outcome. There are at
present two widely used and Food and Drug Administration-approved devices: the AutoPulse, a load-distributed band device that rhythmically compresses and restricts the chest wall and the LUCAS, a piston device with a cup that is placed in the centre of the chest and pushes the sternum down over a distance of 5.2 cm and pulls back to the neutral position. Significant improvement of aortic blood pressure and coronary perfusion pressure is documented in humans from the AutoPulse compared with manual chest compressions. Chest compression with LUCAS resulted in significantly higher end-tidal carbon dioxide in humans compared with manual chest compressions. For several years, only one randomized clinical trial with the AutoPulse was available (ASPIRE), which was terminated after interim analysis because of a trend to reduced survival to discharge compared with manual control CPR. None of the more recent randomized clinical trials demonstrated survival benefit of AutoPulse or LUCAS over manual controls. Anecdotal and possibly biased observations in our hospital and a published letter suggested increased
damage caused by mechanical chest compression devices.”
“The treatment of high-grade carotid-artery stenosis varies considerably internationally. Some countries limit revascularization primarily to patients with symptoms, whereas others more commonly recommend that asymptomatic patients undergo revascularization. In the United States, 75 to 80% of patients who undergo carotid-artery stenting or endarterectomy are asymptomatic. Randomized trials from the 1990s and early 2000s showed that carotid
endarterectomy led to a lower risk of stroke among asymptomatic patients with high-grade
stenosis than medical therapy. Improvements in carotid endarterectomy, carotid-artery
stenting, and medical therapy and the results of two recent small trials have challenged
our understanding of appropriate treatments. Here, we present results from the Carotid
Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trials
(CREST-2), which tested whether carotid artery stenting or carotid endarterectomy plus
intensive medical management would be superior to intensive medical management alone
for preventing stroke in patients with high-grade carotid stenosis without recent stroke
symptoms.”
“Tranexamic acid (TXA) is an antifibrinolytic agent that competitively inhibits the conversion
of plasminogen to plasmin. TXA is also believed to have an anti-inflammatory effect and may improve platelet function under certain circumstances. TXA has increasingly gained recognition in perioperative use to mitigate the risk of postoperative bleeding. Originating in the field of anesthesiology, TXA is used to control surgical, traumatic, and postpartum hemorrhage. Meanwhile, perioperative TXA administration has been established in orthopedic and cardiothoracic surgery. It is also becoming popular in plastic surgery, especially regarding craniomaxillofacial procedures. Although the evidence on
the use of TXA in breast surgery is improving, its value still needs further investigation.”
“The management of IAA remains controversial with different strategies suggested to decrease its incidence: antibiotic prophylaxis, post-operative antibiotic therapy, peritoneal irrigation with saline solution or suction only of the abscess/purulent liquid without irrigation of the cavity during appendectomy. In the literature, many studies address this topic; however, currently there is no evidence to clearly demonstrate the effectiveness of peritoneal irrigation over suction only. Italian guidelines recommend thorough peritoneal lavage (6–8 L of warm saline) and aspiration to minimize the IAA rate in complicated appendicitis. The recent WSES (World Society of Emergency Surgery) guidelines report that “Peritoneal irrigation does not have any advantage over suction alone in complicated appendicitis in both adults and children. The performance of irrigation during laparoscopic appendectomy does not seem to prevent the development of IAA and wound infections
in neither adults nor paediatric patients”. WSES recommendation is “to perform suction only in complicated appendicitis patients with intra-abdominal collections undergoing laparoscopic appendectomy” [QoE: Moderate; Strength of recommendation: Strong; 1B]). The concern regarding irrigation and lavage is that these procedures might help spread the infectious material.”
“High-risk early triple-negative breast cancer is frequently associated with early recurrence and high mortality. Neo-adjuvant chemotherapy is the preferred treatment approach. In addition to potentially increasing the likelihood of tumor resectability and breast conservation, patients who have a pathological complete response after neoadjuvant therapy have longer event-free survival (defined as the time from randomization to the date of disease progression that precluded definitive surgery, the date of local or distant recurrence or the occurrence of a second primary tumor, or the date of death from any
cause) and overall survival. Accordingly, regulatory guidance supports the use of the pathological complete response as an end point for clinical testing of neoadjuvant treatment in patients with early triple-negative breast cancer.”
“This meta-analysis aims to evaluate the comparative outcomes of drain insertion versus no drain after appendicectomy for complicated appendicitis. Abdominal collection, surgical site infection (SSI), bowel obstruction, faecal fistula, paralytic ileus, length of hospital stay (LOS) and mortality were the evaluated outcome parameters for the meta-analysis. Seventeen studies reporting a total number of 4,255 patients who underwent appendicectomy for complicated appendicitis with (n=1,580) or without (n=2,657) drain were included.
There was no significant difference between the two groups regarding abdominal collection (odds ratio (OR)=1.41, P=0.13). No-drain group was superior to the drain group regarding SSI (OR=1.93, P=0.0001), faecal fistula (OR=4.76, P=0.03), intestinal obstruction (OR=2.40, P=0.04) and paralytic ileus (OR=2.07, P=0.01). There was a difference regarding mortality rate between the two groups (3.4% in the drain group vs 0.5% in the no-drain group, risk difference (RD)=0.01, 95% CI (-0.01, 0.04), P=0.36).”
DG: drain group, NDG: no-drain group, RCT: randomized controlled trial, NA: not available.
| Study | Country | Type of the study | Number of patients | Type of operation | Inclusion/exclusion criteria and definition of complicated appendicitis |
| Stone et al., 1978 [25] | Georgia | Retrospective cohort | Total: 94; DG: 49; NDG: 45 | Open | Inclusion and exclusion criteria: NA. Definition of complicated appendicitis: gangrenous or perforated appendicitis |
| Greenall et al., 1978 [26] | United Kingdom | RCT | Total: 103; DG: 48; NDG: 55 | Open | Exclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gangrenous appendicitis, associated with turbid infected fluid |
| Dandapat and Panda, 1992 [27] | India | RCT | Total: 86; DG: 40; NDG: 46 | NA | NA |
| Tander et al., 2003 [28] | Turkey | RCT | Total: 140; DG: 70; NDG: 70 | Open | Inclusion criteria: paediatric cases with uncomplicated perforated appendicitis. Exclusion criteria: appendicular mass/abscess. Definition of complicated appendicitis: gross or microscopic evidence of appendicular perforation with no more discolouration of peritoneal fluid after washing out |
| Narci et al., 2007 [29] | Turkey | Retrospective cohort | Total: 226; DG: 109; NDG: 117 | Open | Inclusion criteria: children with macroscopic perforation. Exclusion criteria: appendix could not be visualized and drained without appendectomy. Definition of complicated appendicitis: macroscopic perforation |
| Allemann et al., 2011 [30] | Switzerland | Case match study | Total: 260; DG: 130; NDG: 130 | Laparoscopic | Exclusion criteria: simple acute appendicitis (i.e., no peritoneal reaction), generalized peritonitis, preoperatively known immunodeficiencies, aged <16 years and incomplete dataset. Definition of complicated appendicitis: localized peritonitis, perforation of the appendix, presence of pus or fibrin membranes around the appendix or frank peri-appendicular abscess |
| Jani and Nyaga, 2011 [31] | Kenya | RCT | Total: 90; DG: 45; NDG: 45 | Open | Inclusion criteria: advanced appendicular pathology and aged over 13 years. Exclusion criteria: simple acute appendicitis or laparoscopic appendicectomy. Definition of complicated appendicitis: perforated, mass or phlegmon |
| Pakula et al., 2014 [32] | USA | Retrospective cohort | Total: 148; DG: 43; NDG: 105 | Laparoscopic | Inclusion criteria: patients with the diagnosis of gangrenous or perforated appendicitis based on the review of pathology and operative reports. Exclusion criteria: simple or suppurative appendicitis and those treated with interval appendectomy. Definition of complicated appendicitis: gangrenous and perforated appendicitis |
| Song and Jung, 2015 [33] | Korea | Retrospective cohort | Total: 342; DG: 108; NDG: 234 | Open: 181; Laparoscopic: 161 | Inclusion criteria: children under 18 years old who were diagnosed with acute appendicitis. Definition of complicated appendicitis: perforated appendicitis |
| Schlottmann et al., 2016 [35] | Argentina | Retrospective cohort | Total: 225; DG: 169; NDG: 56 | Laparoscopic | Inclusion and exclusion criteria: NA. Definition of complicated appendicitis: intraoperatively as the presence of gangrenous/perforated appendicitis with peritonitis |
| Abdulhamid and Sarker, 2018 [36] | Iraq | Retrospective cohort | Total: 227; DG: 114; NDG: 113 | Open | Inclusion criteria: open appendectomy for complicated appendicitis irrespective of age. Definition of complicated appendicitis: perforated with localized abscess formation |
| Aneiros Castro et al., 2018 [37] | Spain | Retrospective cohort | Total: 192; DG: 79; NDG: 63 | Laparoscopic | Inclusion criteria: patients with perforated appendicitis. Exclusion criteria: incidental appendectomy during another laparoscopic surgical procedure and those treated with interval appendectomy. Definition of complicated appendicitis: identifiable macroscopic hole in the appendix during the surgery |
| Miranda-Rosales et al., 2019 [38] | Peru | Retrospective cohort | Total: 150; DG: 50; NDG: 100 | Open | Inclusion criteria: aged >18 years with complicated appendicitis. Exclusion criteria: laparoscopic appendicectomy, patients on anticoagulation, immunocompromised and pregnancy. Definition of complicated appendicitis: localized or generalized peritonitis and appendicular abscess |
| Fujishiro et al., 2021 [39] | Japan | Propensity-matched study | Total: 1,762; DG: 485; NDG: 1304 | Open: 346; Laparoscopic: 958 | Inclusion criteria: complicated appendicitis in children (aged 15 years and below). Exclusion criteria: interval appendectomies. Definition of complicated appendicitis: perforation, gangrene or intra-abdominal abscess |
| Nazarian et al., 2021 [40] | UK | Retrospective cohort | Total: 76; DG: 26; NDG: 50 | Laparoscopic | Inclusion criteria: over the age of 16 with complicated appendicitis. Exclusion criteria: caecal/appendicular malignancy. Definition of complicated appendicitis: histologically proven gangrenous or perforated appendicitis |
| Schmidt et al., 2020 [41] | Germany | Retrospective cohort | Total: 65; DG: 32; NDG: 33 | Open: 11; Laparoscopic: 55 | Inclusion criteria: age range from two to 17 years who presented with perforated appendicitis. Exclusion criteria: severe neurological dysfunction and inflammatory bowel disease. Definition of complicated appendicitis: perforated appendicitis on histology |
| Mustafa et al., 2020 [34] | Pakistan | RCT | Total: 68; DG: 34; NDG: 34 | Open | Exclusion criteria: immunocompromised patients and those with generalized peritonitis (perforated appendix with pus in three or more quadrants of the abdominal cavity visible per-operatively). Definition of complicated appendicitis: perforated appendicitis intra-operatively |
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