A Concern for Intraoperative Distractions and Interference: An Observational Study Identifying, Measuring, and Quantifying Both within the Operating Theatre

Background. Modern surgical research has broadened to include an interest into the investigation of surgical workflow. Rigorous analysis of the surgical process has a particular focus on distractions. Operating theatres are inherently full of distractions, many not pertinent to the surgical process. Distractions have the potential to increase surgeon stress, operative time, and complications. Our study aims to objectively identify, classify, and quantify distractions during the surgical process. Methods. 46 general surgical procedures were observed within a tertiary Irish hospital between June 2019 and October 2019. An established observational tool was used to apply a structured observation to all operations. Additionally, a nine-point ordinal behaviourally anchor scoring scale was used to assign an interference level to each distraction. Results. The total operative observation time was 4605 minutes (mean = 100.11 minutes, std. deviation: 45.6 minutes). Overall, 855 intraoperative distractions were coded. On average, 18.58 distractions were coded per operation (std. deviation: 6.649; range: 5–34), with 11.14 distractions occurring per hour. Entering/exiting (n = 380, 42.88%) and case irrelevant communication (n = 251, 28.32%) occurred most frequently. Disruption rate was highest within the first (n = 275, 32%) and fourth operative quartiles (n = 342, 41%). Highest interference rates were observed from equipment issue and procedural interruptions. Anaesthetists initiated CIC more frequently (2.72 per operation), compared to nurses (1.57) and surgeons (1.17). Conclusion. Our results confirm that distractions are prevalent within the operating theatre. Distractions contribute to significant interferences of surgical workflow. Steps can be taken to reduce overall prevalence and interference level by drawing upon a systems-based perspective. However, due to the ubiquitous nature of distractions, surgeons may need to develop skills to help them resume interrupted primary tasks so as to negate the effects distraction has on surgical outcomes. Data for the above have been presented as conference abstract in 28th International Congress of the European Association for Endoscopic Surgery (EAES) Virtual Congress, 23–26 June 2020.

Whipple’s Pancreatoduodenectomy in the Background of Chronic Liver Disease (CLD): An Institutional Experience

Introduction. Whipple’s pancreatoduodenectomy (PD) is a formidable operation, associated with a high risk of morbidity and mortality. In the setting of an underlying chronic liver disease, the incidence of complications and mortality increases manifold. Patients and Outcomes. Of the 112 Whipple’s PD performed between 2018 to 2020 at a high-volume HPB and liver transplant centre, 4 patients underwent the surgery in the background of an underlying chronic liver disease (CLD). All except one were performed in Child’s A cirrhotics. There was a single 30-day mortality in this series of 4 patients that occurred in the background of Child’s B cirrhosis. On follow-up at 1 year, there was one more mortality in the series, owing to liver decompensation following chemotherapy. Conclusion. Judicious preoperative selection criteria, adequate preoperative nutritional and physiological optimisation, and prudent weighing of risk vs. benefit of undergoing Whipple’s PD in periampullary malignancies in the setting of CLD are the major determinants of the surgical outcome.

Cystic Artery Pseudoaneurysm: Current Review of Aetiology, Presentation, and Management

Background. Cystic artery pseudoaneurysms are rare. Most commonly, they occur secondary to acute cholecystitis or after a cholecystectomy. Complications include haemobilia, biliary obstruction, and haemorrhage. Given the rarity and associated morbidity, a high index of suspicion is required. This article reviews the current literature on cystic artery pseudoaneurysms to investigate its aetiology, clinical presentation, and management options. Methods. A broad search of the Medline and PubMed databases was carried through. All peer reviewed literatures published in the English language between 1991 and 2020 with keywords “cystic” and “artery” and “pseudoaneurysm” in the title were selected for review. No further exclusion criteria; all studies yielded from the search were included in the results of this review. Additionally, we present a case of cystic artery pseudoaneurysm treated at our centre and included this in our analysis. Results. Sixty-seven case reports were found between 1991 and 2020. Aetiologies: Aetiology of cystic artery pseudoaneurysm was found to be cholecystitis in 41 instances (61.2%), cholecystectomy in 18 instances (26.8%), idiopathic in 6 instances (8.9%) cholelithiasis in 1 instance (1.5%), and pancreatitis in 1 instance (1.5%). Complications: Fifty-two cases were complicated by haemobilia (77.6%), 36 by anaemia (53.7%), 25 by biliary obstruction (37.3%), 13 by haemodynamic shock (19.4%), 9 by haemoperitoneum (13.4%), and 6 by contained rupture (8.9%). Most commonly, patients had two or more of these complications. Management: Forty-four patients were managed with endovascular embolisation (65.7%), 21 with endoscopic intervention (31.3%), 18 with open cholecystectomy (26.9%), 13 with laparoscopic cholecystectomy (19.4%), and 6 with pseudoaneurysm ligation (9%). Delayed presentation postcholecystectomy ranged from 8 days to 3 years. Conclusions. Cystic artery pseudoaneurysms are rare complications of a common operation. The most common clinical presentation is haemobilia, which can be difficult to diagnose clinically. A high index of suspicion and prompt investigation with targeted imaging and intervention is required. This is especially pertinent in gastrointestinal bleeding postlaparoscopic cholecystectomy as a missed diagnosis could cause significant morbidity.

Causes and Management Outcome of Small Intestinal Obstruction in Nekemte Referral Hospital, Nekemte, Ethiopia, 2017

Background. Small bowel obstruction is a common and dangerous surgical emergency which is associated with high morbidity and mortality if not managed appropriately and timely. Objective. To determine the causes and management outcome of small bowel obstruction in Nekemte Referral Hospital, Nekemte, Ethiopia. Method. Institution-based retrospective cross-sectional study design was used. Three-year data (from January 1, 2014, to December 30, 2016) were collected from July 1 to August 30, 2017. Data were collected from medical records and checked for any inconsistency, coded, and entered into SPSS version 20 for analysis. Descriptive, binary, and multivariate logistic regression analyses were used. On binary logistic regression analysis, variables with p ≤ 0.25 were selected as a candidate for multivariate logistic regression analysis. The level of statistical significance was set at p ≤ 0.05 . Results. With 100% response rate, records of 211 patients with small intestinal obstruction were retrieved for analysis. One hundred thirty-seven (64.9%) were males. The commonest cause of small bowel obstruction was adhesion (35.1%). More than a quarter (26.5%) participants developed postoperative complications, and wound infection was the commonest postoperative complication (49.2%). A majority (84.8%) of patients improved and were discharged, and the rest 15.2% of patients died. Sex (AOR = 3.98, 95% CI: 1.51–10.52), duration of illness before surgical intervention (AOR = 4.4, 95% CI: 1.69–11.45), level of hematocrit (AOR = 4.25, 95% CI: 1.56–11.57), types of intestinal obstruction (AOR = 3.73, 95% CI: 1.09–12.64), and length of hospital stay (AOR = 4.69, 95% CI: 1.82–12.07) were independent predictors of the management outcome of patients with small bowl obstruction. Conclusion. Small bowel obstruction is a commonly encountered surgical emergency. Adhesion, small bowel volvulus, and intussusception were the leading causes of small bowel obstruction, respectively.

Transurethral Catheterization in Early Training: The Impact of Peer-Led Mentorship

Introduction. Transurethral catheterization (TUC) is a common hospital procedure. According to the literature, junior doctors contribute to the majority of TUC-related injuries. Our aim is to evaluate the immediate and long-term impact of a short procedure-centric TUC workshop on junior doctor’s confidence, procedural knowledge, and ability to identify potential complications of catheterization. Materials and Methods. Intern doctors were invited to attend a one-hour workshop on TUC. A questionnaire was completed before and after the workshop. Three months later, the questionnaire was readministered to assess the workshop’s long-term impact. The questionnaire consisted of three domains. A: experience, training, and confidence levels (using 5-point Likert scales), B: procedural knowledge (the highest possible score was 10 points), and C: identification of TUC-related complications (the highest possible score was 3 points). Results. 81 interns participated and reported a confidence level of 3.03 ± 1.05 in performing a straightforward TUC. Preworkshop domain B and domain C were 3.92 ± 1.63 and 1.75 ± 0.69 points, respectively. After the workshop, reported confidence levels improved to 3.71 + 1.02 ( p < 0.05 ). Likewise, the scores in domains B and C increased significantly to 8.85 ± 1.40 ( p < 0.005 ) and 2.65 ± 0.6 ( p < 0.005 ), respectively. Three months later, the same parameters were evaluated, and confidence levels were higher than those of the preworkshop levels at 3.83 ± 0.77 ( p < 0.05 ). The average domain B score was 7.85 ± 1.88 ( p < 0.005 ), and domain C score was 2.69 ± 0.53 ( p < 0.005 ). All scores reported after three months were significantly better than the preworkshop levels ( p < 0.005 ), but there were no statistically significant differences when compared to the immediate postworkshop scores ( p > 0.05 ). Conclusion. Short peer-led TUC workshops positively impact intern doctors’ confidence levels, procedural knowledge, and identifying complications.

Rare Pseudopapillary Neoplasm of the Pancreas: A 10-Year Experience

Introduction. The solid pseudopapillary epithelial neoplasm (SPN) is a rare form of pancreatic neoplasm with an incidence of 2-3% of all pancreatic tumours. The recent increase in incidence is attributed to the increasing use of imaging techniques for nonspecific abdominal complaints. We report our institutional experience in the management of this tumour over the last decade. Method. We retrospectively analyzed from a prospectively maintained database of patients from January 2011 to December 2020 who were operated upon for SPN. All the patients were followed till date. Results. Of 479 patients operated on for various types of pancreatic tumours during this period, 15 (3.1%) had SPN. The mean age of presentation was 28 years with a female preponderance (12/15, 80%). The most common location was the body and tail of the pancreas (66%), and the mean size was 6.4 cm (2–15 cm). The tumour extent was defined as ‘borderline resectable’ in 20% of cases. Distal pancreatectomy was done in 11 patients with spleen preservation in 3. R0, R1, and R2 resection were done in 12, 2, and 1 patient(s), respectively. The operative mortality was 6.7%. All the patients are doing well on follow-up. Conclusion. SPN is a low-grade malignant tumour with a strong female predilection. Clinical manifestations have no specificity, imaging examination only contributes tumour location, and the final diagnosis rests on pathology. Surgery is the main modality of treatment and carries a good prognosis.

A Fast and Reliable Method to Interpret Short-Term Mortality in Perforated Peptic Ulcer: Red Cell Distribution Width is Sensitive and Specific

Introduction. Peptic ulcer is an important health problem worldwide with a prevalence of around 5%. Peptic ulcer perforation is a potentially mortal complication of peptic ulcer disease. We aimed to investigate the potential use of red cell distribution width as a prognostic marker in peptic ulcer perforation. Methods. The files, operation notes, biochemical and hematological parameters, and prognosis of patients who were operated for a peptic ulcer perforation were reviewed in a retrospective cohort study. The relation of red cell distribution width (RDW) to main outcome in-hospital mortality was assessed. Results. The mean age of the 172 patients was 40 ± 17.89. There were 158 (92%) males and 14 (8%) females. The in-hospital mortality was 8.7% (15/172). The median RDW in the group with mortality was 15.00 (interquartile range (IQR): 14.30–17.20) compared with the median RDW in the group with no mortality as 13.2 (IQR: 12.80–14.00, p ≤ 0.001 ). Receiver operator characteristic curves were plotted for RDW to identify nonsurvivors and yielded a significant area under the curve as 0.812 (95% confidence interval: 0.682–0.942). The sensitivity and specificity of RDW at a cutoff value of 14.25% were calculated with an accuracy of 81.98 (95% confidence interval: 75.40–87.41) as 80.00 (51.91–95.67) and 82.17 (75.27–87.81), respectively. Conclusion. Increased RDW may be of use to interpret mortality in patients with peptic ulcer perforation.

Proposal and Validation of a New Classification of Surgical Outcomes after Colorectal Resections within an Enhanced Recovery Programme

Background. Advantages of Enhanced Recovery (ER) programmes in colorectal surgery have already been demonstrated, but heterogeneity exists with respect to the choice of compared outcomes. A comprehensive classification aimed at standardizing the reporting of surgical outcomes has been proposed and validated. Method. Clinical variables of 231 patients who underwent colorectal resections within an ER programme from 2013–2018 were analysed. Their outcomes have been reported according to a new classification in 5 classes and 11 subclasses. Prognostic variables have been identified. Results. Seventy-nine patients (34.2%) had an optimal class 1 outcome. Almost half of the patients had an uneventful recovery after being discharged after day 4 (2a). Only two patients (0.9%) were discharged early and then readmitted for a minor ailment (2b). Total morbidity was 12.6% (3a–5). Perioperative mortality was 2.6% (5). Young age, laparoscopic resection, and years of experience with ER have been identified as independent prognostic factors towards a totally positive outcome. Conclusions. The proposed outcome classification is a simple and objective tool to report the surgical outcome in clinical studies. Its implementation seems to be appropriate, in particular, in the field of ER protocols in colorectal surgery, but it can have a wider application in any other surgical subspeciality.

Acute Generalized Peritonitis in a Peripheral Hospital Centre in Benin: Can It Be Managed by a Local General Practitioner?

Background. Acute generalized peritonitis in resource-poor countries is still a health challenge due to late diagnosis, surgical delay, and specialists’ unavailability. These are the foremost determinants of surgical morbidity and mortality. We report the experience of a peripheral hospital in Benin not equipped with specialized surgeons. Methods. This is an observational, retrospective, and descriptive study including patients operated for acute generalized peritonitis at the Atacora Departmental Hospital Centre, Benin, where unfortunately CT scan and intensive care unit are still not available. Most of surgical activities were performed by a general practitioner with previous surgical training (but no surgical specialization). Age, gender, cause of peritonitis, surgical procedures, and postoperative outcome were evaluated. Results. Sixty-three patients were included. The mean age was 23.2 years and sex ratio M/F 1.5. The mean surgical delay was 26 hours (range: 6–92 hours). An ileal typhoid perforation was found in 40 patients (63.5%), and 35 of them (87.5%) underwent a primary perforation repair without bowel resection. 73% of surgical procedures were performed by the general practitioner. Morbidity was 34.9% and mortality was 14.3%. The average postoperative hospital stay was 12 days (range: 11–82 days). These results were comparable to those observed in the subgroup of patients (17 cases) operated by the general surgeons (morbidity 32.6%, mortality 13.0%, and average postoperative hospital stay 11 days, range: 1–58 days). Conclusion. Acute generalized peritonitis requires urgent management, and it can be effectively carried out, in a context of limited resources, by a general practitioner with surgical skills.

Appendicectomy for Uncomplicated Simple Appendicitis: Is It Always Required?

Background. Although appendicectomy is still the classical and standard treatment for acute appendicitis, initial conservative antibiotic only treatment for simple uncomplicated cases has been proposed and tried as a feasible and effective approach. The objective of this study was to evaluate the efficacy and outcomes of antibiotics treatment for acute simple uncomplicated appendicitis. Methods. This is a prospective controlled nonrandomized study in which a total of 156 patients whose ages range from 16 to 54 years presenting with clinical diagnosis of acute uncomplicated appendicitis were assigned for conservative antibiotics treatment, which consists of ceftriaxone I gram twice daily and metronidazole infusions, 500 mg in 100 ml, 3 times daily for 48 to 72 hours to be converted on oral antibiotics after clinical improvement for 5 to 7 days. Patients who failed to initial conservative treatment and those who had recurring symptoms of appendicitis were presented for appendectomy. Results. Antibiotic treatment was successful and feasible in 138 (88.5%) patients. Progression of the signs and symptoms despite full medical treatment was observed in 11 (7%) patients during the same admission. Further 7 (4.5%) patients showed recurrence of the symptoms during follow-up period of 6–12 months after successful initial conservative treatment and also proceeded for appendicectomy. Conclusion. Nonoperative antibiotic treatment of acute simple appendicitis is safe, feasible, and effective for properly selected cases, thus avoiding unnecessary surgery with its possible complications.