Lung transplantation for lung cancer: A systematic review of the literature.

BACKGROUND: Lung transplant (LTx) is an accepted treatment for end-stage pulmonary failure. A small proportion of explanted lungs harbor incidentally identified nonsmall cell lung cancers (NSCLC). We review the literature on studies assessing LTx patients found to have NSCLC lung cancer in their explanted lungs, and perform a pooled analysis of outcomes. METHODS: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. We included studies assessing outcomes of patients with incidentally identified NSCLC following LTx, or following LTx for diffuse lepidic adenocarcinoma as a primary indication. RESULTS: A total of 1404 articles were reviewed. 17 eligible studies were identified: 14 studies on incidental NSCLC (N = 169), 4 on diffuse lepidic adenocarcinoma (N = 70). Overall survival (OS) for patients with incidentally identified lung cancer at 1-year, 3-year, and 5-year was 60.8% (95%CI 43.7%-77.9%, I2 =81.8%), 25.5% (95%CI 1.6%-49.5%, I2 =93.6%), and 23.0% (95%CI 2.0%-44.0%, I2 =92.0%) respectively. When restricted to those with earlier stage disease, those with stage I or II NSCLC had better 1-year, 3-year, and 5-year OS at 72.7% (95%CI 57.2%-88.2%, I2 =67.3%), 41.6% (95%CI 14.0%-69.1%, I2 =89.1%), and 34.5% (95%CI 8.1%-61.0%, I2 =89.8%), respectively. A sensitivity analysis limited to stage I showed 1-year, 3-year, and 5-year survival of 73.0% (95%CI 56.3%-89.7%), 40.4% (95%CI 110.3%-70.6%), and 35.4% (95%CI 6.2%-64.5%), respectively. The 4 studies on diffuse lepidic adenocarcinoma were too heterogeneous for pooled analysis. CONCLUSIONS: We present a review and pooled analysis examining survival following LTx with incidentally identified NSCLC. Patients with earlier stage incidentally explanted NSCLC had better survival outcomes. OS in the stage I population approximates that of LTx without incidental NSCLC.

Impact of surgeon and hospital factors on length of stay after colorectal surgery systematic review.

BACKGROUND: Although length of stay (LOS) after colorectal surgery (CRS) is associated with worse patient and system level outcomes, the impact of surgeon and hospital-level factors on LOS after CRS has not been well investigated. The aim of this study was to synthesize the evidence for the impact of surgeon and hospital-level factors on LOS after CRS. METHODS: A comprehensive database search was conducted using terms related to LOS and CRS. Studies were included if they reported the effect of surgeon or hospital factors on LOS after elective CRS. The evidence for the effect of each surgeon and hospital factor on LOS was synthesized using vote counting by direction of effect, taking risk of bias into consideration. RESULTS: A total of 13 946 unique titles and abstracts were screened, and 69 studies met the inclusion criteria. All studies were retrospective and assessed a total of eight factors. Surgeon factors such as increasing surgeon volume, colorectal surgical specialty, and progression along a learning curve were significantly associated with decreased LOS (effect seen in 87.5 per cent, 100 per cent, and 93.3 per cent of studies respectively). In contrast, hospital factors such as hospital volume and teaching hospital status were not significantly associated with LOS. CONCLUSION: Provider-related factors were found to be significantly associated with LOS after elective CRS. In particular, surgeon-related factors related to experience specifically impacted LOS, whereas hospital-related factors did not. Understanding the mechanisms underlying these relationships may allow for tailoring of interventions to reduce LOS.

Water-soluble contrast in the management of adhesive small-bowel obstruction: a Canadian centre's experience with guideline development and implementation.

BACKGROUND: Orally administered water-soluble contrast (WSC) can track resolution of small-bowel obstruction (SBO), but no universal pathway for its use exists. We developed and implemented an evidence-based guideline for the use of WSC in the management of adhesive SBO, to be implemented across hospitals affiliated with the University of Toronto. METHODS: We performed a systematic review and created a clinical practice guideline for WSC use in the management of adhesive SBO. The guideline was approved through consensus by an expert panel and implemented in 2018. We performed a prospective cohort study of guideline implementation at 1 pilot site (a large academic tertiary care centre), facilitated by the centre's acute care general surgery service. Primary outcomes included compliance with the guideline and hospital length of stay (LOS). Secondary outcomes included rates of failure of nonoperative management, morbidity, mortality and readmission for recurrence of SBO within 1 year. Patients with adhesive SBO admitted in 2016 served as a control cohort. RESULTS: We analyzed the data for 152 patients with adhesive SBO admitted to the centre, 65 in 2016 (historical cohort), 56 in January-June 2018 (transitional cohort) and 31 in July-December 2018 (implementation cohort). There was a significant increase in compliance with the WSC protocol in 2018, with the proportion of patients receiving WSC increasing from 45% (n = 25) in the transitional cohort to 71% (n = 22) in the implementation cohort (p < 0.001). The median LOS did not differ across the cohorts (p = 0.06). There was a significantly lower readmission rate in the transitional and implementation cohorts (13 [23%] and 9 [29%], respectively) than in the historical cohort (29 [45%]) (p = 0.04). Among patients assigned to nonoperative management initially, a significantly higher proportion of those who received WSC than those who did not receive WSC went on to undergo surgery (14.6% v. 3.6%, p = 0.01), with no difference in median time to surgery (p = 0.2). CONCLUSION: An evidence-based guideline for WSC use in SBO management was successfully developed and implemented; no difference in LOS or time to surgery was seen after implementation, but rates of immediate operation increased and readmission rates decreased. Our experience shows that implementation of an evidence-based clinical practice guideline is feasible through multidisciplinary efforts and coordination.

Reviewing the Reviewers Potential Financial Conflicts of Interest in Editorial Boards of Surgery Journals.

OBJECTIVE: To assess the prevalence, magnitude, and disclosure status of industry funding in editorial boards of surgery journals. SUMMARY OF BACKGROUND DATA: Financial COI can bias research. Although authors seeking to publish in peer-reviewed surgery journals are required to provide COI disclosures, editorial board members' COI disclosures are generally not disclosed to readers. METHODS: We present a cross-sectional analysis of industry funding to editorial board members of high-impact surgery journals. We reviewed top US-based surgery journals by impact factor to determine the presence of financial COI in members of each journal's editorial board. The prevalence and magnitude of COI was determined using 2018 industry reported payments found in the Centers for Medicare and Medicaid Services Open Payments database. Journal websites were also reviewed looking for the presence of editorial board disclosure statements. RESULTS: A total of 1002 names of editorial board members from the top 10 high-impact American surgery journals were identified. Of 688 individual physicians based in the USA, 452 (65.7%) were found to have received industry payments in 2018, totaling $21,916,503 with a median funding amount per physician of $1253 (interquartile range $156-$10,769). Funding levels varied by surgical specialty and journal. Editorial board disclosure information was found in only 3.3% of physicians. CONCLUSIONS: Industry funding to editorial board members of high impact surgery journals is prevalent and underreported. Mechanisms of disclosure for COI are needed at the editorial board level to provide readers full transparency. This would acknowledge this COI of editorial board members, and thereby attempt to potentially further reduce the risk of bias in editorial decisions.

Oesophageal rupture from a pneumatic blast injury: an unusual mechanism of blunt oesophageal trauma.

Oesophageal perforation is a serious condition associated with significant morbidity and mortality. Clinical suspicion of oesophageal injury in patients sustaining neck or torso trauma is essential as early diagnosis and management are associated with better outcomes. Oesophageal perforation resulting from blunt trauma is uncommon, and traumatic oesophageal perforation following blast injury is exceedingly rare. We present two cases of patients developing oesophageal perforation from this rare mechanism, review basic principles of management, and key learning points.

Wound protectors in reducing surgical site infections in lower gastrointestinal surgery: an updated meta-analysis.

BACKGROUND: Surgical site infection (SSI) is a common complication in gastrointestinal surgery. Wound protection devices are being increasingly used in the attempt to reduce infection rates. We performed a meta-analysis to determine if wound protectors reduce the incidence of SSIs in lower gastrointestinal surgery. METHODS: MEDLINE and EMBASE databases were searched between 1946 and 2016. Randomized controlled trials comparing wound protector versus no wound protector in lower gastrointestinal surgery were included. Our primary outcome was surgical site infection. Subgroup analysis was conducted comparing single-ring versus dual-ring wound protectors. RESULTS: Twelve RCTs with 3029 participants were included. There was a significant decrease in the odds of developing SSI in the wound protector group (OR 0.64, 95% CI 0.45-0.90, P < 0.01, I 2 = 55%). There was evidence of a subgroup effect (P = 0.01) with dual-ring wound protectors associated with significantly lower incidence of SSIs (OR 0.31, 95% CI 0.18-0.52, P < 0.0001, I 2 = 12%), which was not appreciated in the single-ring group (OR 0.84, 95% CI 0.67-1.04, P = 0.11, I 2 = 0%). CONCLUSIONS: Wound protector use is associated with decreased odds of developing SSI in patients undergoing lower gastrointestinal surgery. There was a subgroup effect when comparing dual-ring to single-ring devices.

Assessment of Conflicts of Interest in Robotic Surgical Studies: Validating Author's Declarations With the Open Payments Database.

BACKGROUND: Accurate conflict of interest (COI) statements are important, as a known COI may invalidate study results due to the potential risk of bias. OBJECTIVE: To determine the accuracy of self-declared COI statements in robotic studies and identify risk factors for undeclared payments. METHODS: Robotic surgery studies were identified through EMBASE and MEDLINE and included if published in 2015 and had at least one American author. Undeclared COI were determined by comparing the author's declared COI with industry reported payments found in the "Open Payments" database for 2013 and 2014. Undeclared payments and discrepancies in the COI statement were determined. Risk factors were assessed for an association with undeclared payments at the author and study level. RESULTS: A total of 458 studies (2253 authors) were included. Approximately, 240 (52%) studies had 1 or more author receive undeclared payments and included 183 where "no COI" was explicitly declared, and 57 with no declaration statement present. Moreover, 21% of studies and 18% of authors with a COI declared it so in a COI statement. Studies that had undeclared payments from Intuitive were more likely to recommend robotic surgery compared with those that declared funding (odds ratio 4.29, 95% confidence interval 2.55-7.21). CONCLUSIONS: We found that it was common for payments from Intuitive to be undeclared in robotic surgery articles. Mechanisms for accountability in COI reporting need to be put into place by journals to achieve appropriate transparency to those reading the journal article.

The Effect of Antibiotic-Coated Sutures on the Incidence of Surgical Site Infections in Abdominal Closures: a Meta-Analysis.

OBJECTIVE: This meta-analysis aims to determine if antibiotic-impregnated sutures for abdominal fascial closure prevent postoperative surgical site infections (SSIs), hernias, and/or dehiscence. METHODS: MEDLINE and EMBASE databases (1946-2016) were searched. Randomized controlled trials comparing antibiotic-impregnated sutures to standard sutures for abdominal closure were eligible. Risk of bias was evaluated using the Cochrane Handbooks definitions. RESULTS: Four-hundred fifty articles were reviewed; five eligible studies (N = 3117) were identified. All studies routinely used prophylactic antibiotics. Overall risk of SSI in the antibiotic-impregnated suture group was 10.4 vs. 13.0% in the control group. Pooled data showed no difference in SSI between suture types (odds ratio 0.79, 95% CI 0.57-1.09, P = 0.15, I 2 = 44%). There was no evidence of subgroup effect by suture material (polydioxanone vs. polyglactin 910; P = 0.19) or by comparing colorectal surgery studies to others (P = 0.67). There was a high risk of bias in two studies, one for high loss to follow-up and one for not using an intent-to-treat analysis. CONCLUSION: Our meta-analysis is the most comprehensive review on the utility of antibiotic-impregnated sutures in abdominal surgery to prevent SSI. We found no evidence to support routine use of these sutures.