Surgeries

The operating room in a cardiothoracic surgical case is a complex environment, with multiple handoffs often required by staffing changes, and can be variable from program to program. This study was done to characterize what types of practitioners provide anesthesia during cardiac operations to determine the variability in this aspect of care. A survey was sent out via a list serve of members of the cardiac surgical team. Responses from 40 programs from a variety of countries showed variability across every dimension requested of the cardiac anesthesia team. Given that anesthesia is proven to have an influence on the outcome of cardiac procedures, this study indicates the opportunity to further study how this variability influences outcomes and to identify best practices. Full article

We present a case of a 75-year-old patient who underwent reconstruction of the lower eyelid and lateral canthus following removal of 80% of the lower eyelid due to basal cell carcinoma. A Hughes transconjunctival eyelid-sharing flap was used to form the posterior lamella, and a free skin graft from the ipsilateral upper lid was used to recreate the anterior lamella. The lateral canthal ligament was reconstructed using a free fascia lata graft. A periosteal flap was not used due to local scarring that was the result of previous multiple lateral canthal surgeries. Skin preservation in the lateral canthal area and additional horizontal support for the lower eyelid were achieved by using a local advancement flap. This two-stage surgery produced excellent functional and cosmetic effects. Fascia lata free graft can be an alternative to the periosteal flap for reconstruction of the lateral canthal ligament when use of the lateral orbital periosteum is not feasible. Full article

Patient-reported outcome measures (PROMs) have become an important aspect of quality control in modern healthcare. In this prospective observational study on 199 patients undergoing thoracolumbar stabilization surgery, we quantified preoperative expectations and PROMs at six and twelve months after surgery, and we investigated what constitutes patient satisfaction with the outcome. We used the visual analogue scale (VAS) for pain and the Oswestry Disability Index (ODI). Preoperative expectations were high (expected ODI: 9 ± 13%; leg pain: 1.0 ± 1.4; back pain: 1.3 ± 1.5). Pain and disability improved substantially, but expectations were mostly unrealistic (ODI expectation fulfilled after six months: 28% of patients; back pain: 48%). However, satisfaction was high (70% at six months after surgery). Satisfied patients had significantly better pain and disability outcomes and higher rates of expectation fulfillment than non-satisfied patients. Patients undergoing revision stabilization had worse outcomes than all other diagnosis groups. Prior stabilization surgery was identified as an independent risk factor for dissatisfaction. There were no preoperative pain or disability levels that predicted dissatisfaction. The data presented in this study can provide benchmarks for diagnosis-specific PROM targets in thoracolumbar stabilization surgery. Future studies should investigate whether satisfaction can be influenced, e.g., by discussing realistic outcome targets with patients ahead of surgery. Full article

Spinal dural arterio-venous fistulas (SDAVF) are rare vascular pathologies. Degree of symptom improvement after surgery remains unclear. We evaluated surgically treated SDAVF patients for functional outcome and symptom improvement. Retrospective inclusion of consecutive patients treated surgically in our department between 2007–2019. We measured functional outcome using the McCormick Scale and modified Japanese Orthopaedic Association (mJOA) score. We included 27 patients with a median follow-up of 8.8 months (IQR 27.8). Mean age was 61.8 years (SD 8.4), 40.7% were female. Most frequent location was the thoracic spine in 15 (55.6%) followed by lumbar in 8 (29.6%), cervical in 3 (11.1%) and sacral spine in one patient (3.7%). Most common presenting symptom was progressive myelopathy (24/27 patients, 88.9%). In all patients the SDAVF was completely resected; however, four patients (14.8%) required a second surgery. Six patients (22.2%) deteriorated immediately after surgery with five recovering to baseline upon discharge. On discharge, presenting symptoms had improved in 17 patients (63%); 8/25 patients (32%) had a McCormick score of 1. Twenty (74.1%) continued to improve on follow-up. In total 23/27 patients (85.2%) improved. In the univariable analysis mJOA score on admission was associated with mJOA score on follow-up (coefficient 0.6, 95%CI 0.4–0.81, p < 0.001), whereas age was inversely associated (coefficient −0.1, 95%CI −0.19–0.01, p = 0.08). Untreated SDAVF leads to progressive myelopathy which may result in considerable disability. Surgical disconnection and resection provides a safe treatment option with low perioperative morbidity and excellent chances for symptom improvement or progression prevention. Full article

Warthin’s tumor (WT) is the second most common benign tumor of the parotid gland. Located almost exclusively in the parotid gland and presenting a slow growth rate, WT usually does not exceed 4 cm and rarely benefits from early surgical treatment. The aim of this paper is to present a case of giant parotid Warthin’s tumor. The occurrence of large and deforming WT is rare, previous research showed a single similar reported case. The patient’s computed tomography scans showed a solid and cystic 15 × 13 cm² mass of the parotid gland, without visible signs of invading the adjacent structures. Superficial parotidectomy with tumor excision was performed, with preservation of glandular and facial nerve functions. The paper also presents a brief literature review addressing the main controversies regarding etiopathology, epidemiology, diagnostic methods and treatment options for this parotid gland tumor. Full article

Due to increasing life expectancy and improved diagnostic sensitivity, a growing number of older patients are presenting with resectable pancreatic disease entities and are being evaluated for surgery. Intended as an internal quality control for patient selection, we aimed at evaluating septuagenarians and octogenarians compared with patients younger than 70 years of age regarding early postoperative outcome in general, and long-term oncologic outcome in the case of resection for pancreatic adenocarcinoma. A total number of 1231 patients who underwent pancreatic resection for any entity between 2007 and 2019 at our tertiary university medical center in Germany were retrospectively analyzed, accessing a prospectively maintained database. Participants were divided into three groups based on age (<70 years: N = 761; 70–79 years: N = 385; 80–89 years: N = 85) and were evaluated with regard to perioperative variables, postoperative morbidity, mortality and overall survival for the subgroup of patients with pancreatic adenocarcinoma. Pancreatic resection in older individuals was not infrequent. When surgery was performed for carcinoma, patients >70 years of age even constituted almost half of the cases. In spite of increased American Society of Anesthesiologists physical status classification (ASA)-scores and more frequent comorbidities in older patients, similar rates for postoperative morbidity and mortality were observed in all age groups. A significant disparity in the use of (neo-) adjuvant therapy between younger and older pancreatic adenocarcinoma patients was detected. However, median overall survival did not significantly differ between all age groups (<70 years: 28 (95%-CI: 22–34) months; 70–79 years: 21 (17–25) months; 80–89 years: 15 (9–21) months). In conclusion, elderly patients can experience similar perioperative outcomes to those of younger individuals after major pancreatic surgery. The survival benefit from resection of localized pancreatic adenocarcinoma is largely independent of patient age. The results are reassuring with respect to our preoperative practice and clinical judgment regarding careful patient selection. Future randomized trials should decidedly include elderly patients to generate more robust evidence to further optimize treatment recommendation and choice. Full article

Introduction. Knowledge of fecal incontinence (FI) in medical professionals is poor. Undergraduate education is limited despite its relevance to many specialties. Our aim was to review undergraduate curriculum requirements for FI across the UK and evaluate the impact of a teaching tool on medical student knowledge. Methods. Governing bodies and medical school curricula were identified and searched for FI knowledge requirements. A questionnaire was developed to assess undergraduate exposure to FI teaching. This information was consolidated with a discussion group involving medical students and used to develop an e-learning module. Intervention was performed by trialing the module in a group of medical students and evaluated with feedback. Results. There is a considerable absence of undergraduate learning requirements for FI. Only 19% of medical students had received teaching on the subject despite there being a demand for more coverage (43%). A group discussion guided the development of an e-learning module. Introduction of this significantly improved medical students understanding in all aspects of diagnosis and management of FI. Conclusions. There is a shortfall in the undergraduate curriculum requirements for this common and debilitating problem. An e-learning module can enhance knowledge and understanding in medical students to improve patient care and management. Full article

Low anterior resection syndrome (LARS) is recognised as disordered bowel function after rectal resection. Temporary ileostomy is associated with LARS and with reduced colonic bacteria. Faecal microbiota transplant (FMT) is the introduction of enteric bacteria from healthy donors into a patient’s gut. We hypothesise that FMT could improve bowel function after ileostomy reversal. We aim to determine whether FMT would be acceptable to patients. Patients who had undergone anterior resection in the previous two years across four sites were sent questionnaires. A group of patients were invited to a focus group to explore their views further. There were 98 eligible patients, of whom 40 responded (41%); 67% were male, median age was 67 (range 31–83) years, and 11 still had a stoma. Of those who had their stoma reversed, 52% had major LARS symptoms. Sixty-five percent thought the concept of FMT sounded effective and 70% were willing to try it. A healthy anonymous donor and FMT via enema were the most acceptable options to the respondents. Seven patients attended the focus group; 2 female, 5 male, mean age 66 (range 45–75) years. All patients thought FMT was acceptable but the word “faecal” made it less acceptable. All participants would consider entering a trial with FMT as a treatment option. The main concerns were safety and efficacy. The majority of patients who responded thought FMT was acceptable and were willing to try it as a potential treatment option. Full article

(1) Background: Lateral or total parotidectomy are the standard surgical treatments for malignant parotid tumors. However, some authors have proposed a more limited procedure. (2) Methods: We performed a review of the literature on this topic. Studies were included that met the following criteria: malignant parotid tumors, information about the extent of surgical resection, treated with less than a complete lateral lobectomy, and information on local control and/or survival. Nine articles fulfilled the inclusion criteria. (3) Results: Eight of the nine series reported favorable results for the more limited approaches. Most used them for small, mobile, low-grade cancers in the lateral parotid lobe. Most authors have used a limited partial lateral lobectomy for a presumed benign lesion. The remaining study analyzed pediatric patients treated with enucleation with poor local control. (4) Conclusions: There is weak evidence for recommending less extensive procedures than a lateral parotid lobectomy. In the unique case of a partial lateral parotidectomy performed for a tumor initially thought to be benign but pathologically proved to be malignant, close follow-up can be recommended for low grade T1 that has been excised with free margins and does not have adverse prognostic factors. Full article