Risk Factors, Diagnosis and Management of Chyle Leak Following Esophagectomy for Cancers: An International Consensus Statement.

This Delphi exercise aimed to gather consensus surrounding risk factors, diagnosis, and management of chyle leaks after esophagectomy and to develop recommendations for clinical practice. Background: Chyle leaks following esophagectomy for malignancy are uncommon. Although they are associated with increased morbidity and mortality, diagnosis and management of these patients remain controversial and a challenge globally. Methods: This was a modified Delphi exercise was delivered to clinicians across the oesophagogastric anastomosis collaborative. A 5-staged iterative process was used to gather consensus on clinical practice, including a scoping systematic review (stage 1), 2 rounds of anonymous electronic voting (stages 2 and 3), data-based analysis (stage 4), and guideline and consensus development (stage 5). Stratified analyses were performed by surgeon specialty and surgeon volume. Results: In stage 1, the steering committee proposed areas of uncertainty across 5 domains: risk factors, intraoperative techniques, and postoperative management (ie, diagnosis, severity, and treatment). In stages 2 and 3, 275 and 250 respondents respectively participated in online voting. Consensus was achieved on intraoperative thoracic duct ligation, postoperative diagnosis by milky chest drain output and biochemical testing with triglycerides and chylomicrons, assessing severity with volume of chest drain over 24 hours and a step-up approach in the management of chyle leaks. Stratified analyses demonstrated consistent results. In stage 4, data from the Oesophagogastric Anastomosis Audit demonstrated that chyle leaks occurred in 5.4% (122/2247). Increasing chyle leak grades were associated with higher rates of pulmonary complications, return to theater, prolonged length of stay, and 90-day mortality. In stage 5, 41 surgeons developed a set of recommendations in the intraoperative techniques, diagnosis, and management of chyle leaks. Conclusions: Several areas of consensus were reached surrounding diagnosis and management of chyle leaks following esophagectomy for malignancy. Guidance in clinical practice through adaptation of recommendations from this consensus may help in the prevention of, timely diagnosis, and management of chyle leaks.

Influence of body composition measures on chyle leak after oesophagectomy.

Background: Chyle leak (CL) is an infrequent but potentially serious complication of oesophagectomy. Sarcopenia is an increasingly recognised prognostic factor in oesophageal cancer surgery. The aim of this study was to identify the influence of body composition measures on CL following oesophagectomy. Methods: Patients who developed CL after oesophagectomy between January 2006-December 2020 were identified retrospectively from a prospectively maintained dataset. A control group of patients undergoing oesophagectomy, who did not experience chyle leak during the same time period, was also collected. Relationships between CL and demographics, operative factors and body composition measures were investigated as primary outcomes. Risk factors for severe CL were evaluated as a secondary outcome. Results: There were 26 patients who developed a CL following an oesophagectomy. On univariate analysis, preoperative body mass index (BMI) (P=0.001), subcutaneous fat index (P=0.001) and total fat index (P=0.004) were significantly associated with CL. On multivariate analysis, a lower preoperative subcutaneous fat index was a significant independent predictor of CL (P=0.003). Sarcopenia, as an overall measure, was not found to be a significant predictor of developing CLs. No significant predictors of severe CL were identified. Conclusions: A reduced preoperative BMI and body fat composition are risk factors for CL after oesophagectomy. Sarcopenia does not predict either the occurrence or severity of CL. This presents potentially modifiable risk factors for CL after oesophagectomy and emphasises the importance of physiological and nutritional optimisation before oesophagectomy.

Corrigendum to "The psychosocial impact of surgical complications on the operating surgeon: A scoping review" [Ann. Med. Surg. 67 (July 2021) 102530].

[This corrects the article DOI: 10.1016/j.amsu.2021.102530.].

The psychosocial impact of surgical complications on the operating surgeon: A scoping review.

BACKGROUND AND AIM: Surgical complications are common, and their management is an integral part of surgical care. The impact on the surgeon, the "second victim" is significant, particularly in terms of psychological health. The aim of this review is to describe the nature of psychosocial consequences of surgical complications on the surgeons involved. METHOD: Following scoping review protocols, we set out to identify the evidence-base for psychosocial consequences on the operating surgeon, predominantly general surgeons, following surgical complications. RESULTS: This scoping review identified 19 articles, mainly survey and interview based (n = 8), with all but one article from first world countries. Seven articles reported on negative emotions or depressive behavioural responses. All original studies reported on difficulty in coping (37.5%), and a range of behaviours. There was little evidence for support structures or active interventions to aid the surgeon post complication. CONCLUSIONS: The review suggests that the psychosocial impact, following a complication, is variable but affects every surgeon irrespective of the level of impact on the patient. The main variables differentiating impact are severity, and outcome of the complication and seniority of the surgeon. Reported emotions and behaviours were generally negative and persist across the surgeon's journey towards recovery. Surgeons who manage stress well exhibit largely constructive behaviours and actively work to recover. Identification of variables underpinning complications, and affected surgeons is paramount, as is the provision of services to support recovery. Efforts should be made to proactively prevent complications, via education, awareness and to formalise support processes.

Suture Cruroplasty Versus Mesh Hiatal Herniorrhaphy for Large Hiatal Hernias (HHs): An Updated Meta-Analysis and Systematic Review of Randomized Controlled Trials.

BACKGROUND: To explore the clinical outcomes, safety and effectiveness of suture cruroplasty versus mesh repair for large hiatal hernias (HHs) by an updated meta-analysis. MATERIAL AND METHODS: Randomized controlled trials evaluating the effects of these 2 treatment modalities were searched from PubMed and other electronic databases between January 1991 and July 2018. The outcome variables analyzed included operating time, complications, recurrence of HH or wrap migration, reoperation, hospital stay and quality of life. RESULTS: Five randomized controlled trials totaling 478 patients (suture=222, mesh=256) were analyzed. For reoperation variable, the odds ratio was significantly 3.26 times higher for the suture group. For recurrence of HH, the odds ratio for the suture group was nonsignificantly 1.65 times higher compared with the mesh group. Comparable effects were noted for all other variables. CONCLUSIONS: Mesh repair seems to be superior to suture cruroplasty for large HH repair. Therefore, the routine use of mesh may be advantageous in selected cases.

Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Partial fundoplication is commonly performed in conjunction with Heller Myotomy. It is, however, controversial whether anterior Dor or posterior Toupet partial fundoplication is the antireflux procedure of choice. The aim was to perform a systematic review and meta-analysis of studies comparing these two procedures. MATERIAL AND METHODS: A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, Google scholar and current contents for English language articles comparing Dor and Toupet fundoplication following HM between 1991 and 2018 was performed. The outcome variables analyzed included operating time, length of hospital stay (LOHS), overall complication rate, quality of life (QOL), postoperative reflux, residual postoperative dysphagia, treatment failure and reoperations. The meta-analysis was prepared in accordance with the PRISMA-P statement. RESULTS: Seven studies totaling 486 patients (Dor = 245, Toupet = 241) were analyzed. LOHS was significantly shorter for Toupet repair compared to Dor procedure (WMD 0.73, 95% CI 0.47 to 0.99; P < 0.0001). Furthermore, patients after Toupet experienced significantly better QOL than those after Dor (WMD 1.68, 95% CI 0.68 to 2.73, P < 0.001). All other variables showed comparable effects for these two procedures. CONCLUSION: Our systematic review and meta-analysis revealed that Toupet fundoplication is superior to Dor in terms of LOHS and QOL following HM. For other variables such as postoperative reflux, postoperative dysphagia, complication rates and treatment failure, both Dor and Toupet fundoplication produced effective and equivalent results.

Correction to: Causes of recurrence in laparoscopic inguinal hernia repair.

In the original publication, affiliation 3 was incorrectly published for the author 'Darius Ashrafi'. The correct affiliation should read as 'Department of Surgery, Sunshine Coast University Hospital, Birtinya, QLD, Australia.

Causes of recurrence in laparoscopic inguinal hernia repair.

PURPOSE: Recurrence after laparoscopic inguinal herniorrhaphy is poorly understood. Reports suggest that up to 13% of all inguinal herniorrhaphies worldwide, irrespective of the approach, are repaired for recurrence. We aim to review the risk factors responsible for these recurrences in laparoscopic mesh techniques. METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents and PubMed databases identified English language, peer reviewed articles on the causes of recurrence following laparoscopic mesh inguinal herniorrhaphy published between 1990 and 2018. The search terms included 'Laparoscopic methods', 'Inguinal hernia; Mesh repair', 'Recurrence', 'Causes', 'Humans'. RESULTS: The literature revealed several contributing risk factors that were responsible for recurrence following laparoscopic mesh inguinal herniorrhaphy. These included modifiable and non-modifiable risk factors related to patient and surgical techniques. CONCLUSIONS: Recurrence can occur at any stage following inguinal hernia surgery. Patients' risk factors such as higher BMI, smoking, diabetes and postoperative surgical site infections increase the risk of recurrence and can be modified. Amongst the surgical factors, surgeon's experience, larger mesh with better tissue overlap and careful surgical techniques to reduce the incidence of seroma or hematoma help reduce the recurrence rate. Other factors including type of mesh and fixation of mesh have not shown any difference in the incidence of recurrence. It is hoped that future randomized controlled trials will address some of these issues and initiate preoperative management strategies to modify some of these risk factors to lower the risk of recurrence following laparoscopic inguinal herniorrhaphy.

Free Intraperitoneal Gallstone: An Unusual Case of Small Bowel Obstruction from Extrinsic Compression.

Laparoscopic cholecystectomy (LC) is preferred in the treatment of symptomatic cholecystolithiasis. Gallstone spillage is not uncommon, and there have been reports of associated complications. We report a case of a free intraperitoneal gallstone, left inadvertently during LC, which developed an inflammatory phlegmon with abscess containing gallstone, causing extraluminal compression on the distal ileum, resulting in small bowel obstruction. This complication in particular is almost unheard of. The patient underwent laparoscopic drainage of abscess and retrieval of gallstone, which relieved the obstruction. Clinicians, therefore, need to keep an open mind in the workup for bowel obstruction. During LC, gallstone spillage should be prevented and retrieved whenever possible to minimize early and late complications associated with it.

Research during medical school: is it particularly difficult in developing countries compared to developed countries?

OBJECTIVES: Medical student involvement in research has been declining over the years. We reviewed the factors that hinder participation in research with a focus on developing countries. METHODS: Literature search was performed using PubMed, MEDLINE and Cochrane Library. Peer-reviewed articles published between 1995 and 2017 were screened for relevance to identify key factors affecting medical student involvement in research with a particular focus on developing world. Analytical review is presented here in this article in relation to commonly reported aspects related to research during medical school. RESULTS: This search revealed varied contributing factors that hinder students' growth and interest in research. It commonly highlighted few aspects in relation to research during medical school, and they were "variability in research uptake among students and issues related to them, their knowledge and attitude toward research and organizational input and its influence on students". CONCLUSION: While early introduction to research by inculcating a mindset aimed at research has been proposed, it has not been seen in practice during either the medical school or beyond to an extent that was expected. It appears that developing countries, while they share some of the reasons with developed countries, have their own set of difficulties, which are influenced by culture, beliefs and priorities.

A New Era of Minimally Invasive Surgery: Progress and Development of Major Technical Innovations in General Surgery Over the Last Decade.

Minimally invasive surgery (MIS) continues to play an important role in general surgery as an alternative to traditional open surgery as well as traditional laparoscopic techniques. Since the 1980s, technological advancement and innovation have seen surgical techniques in MIS rapidly grow as it is viewed as more desirable. MIS, which includes natural orifice transluminal endoscopic surgery (NOTES) and single-incision laparoscopic surgery (SILS), is less invasive and has better cosmetic results. The technological growth and adoption of NOTES and SILS by clinicians in the last decade has however not been uniform. We look at the differences in new developments and advancement in the different techniques in the last 10 years. We also aim to explain these differences as well as the implications in general surgery for the future.

Complications, Implications, and Prevention of Electrosurgical Injuries: Corner Stone of Diathermy Use for Junior Surgical Trainees.

Diathermy is commonly used in modern-day surgery. The incidence of electrosurgical injuries related to diathermy is under reported, as it is difficult to ascertain the true impact on both patient and healthcare professionals. As junior surgical trainees, understanding of the mechanism and biophysics of the electrosurgical tools enables safer usage and contributes to improved outcome. Careful use of electrosurgical tools during operation and appropriate communication amongst staff members are pivotal to a safe surgical outcome. Here, we discuss the causes and risk factors regarding electrosurgical complications along with suggestions to ensure safe practice, focusing on commonly neglected areas.

Mastery learning: how is it helpful? An analytical review.

The desire to be good at one's work grows out of the aspiration, competition, and a yearning to be the best. Surgeons, in their aim to provide the best care possible to their patients, adopt this behavior to achieve high levels of expert performance through mastery learning, and the surgical training attempts to prepare them optimally to lead a virtuous and productive life. The proponents of the framework reject evidence that suggests that other variables are also necessary to achieve high levels of expert performance. Here, we review various models and designs to achieve mastery along with their pros and cons to help us understand how mastery learning is helpful in surgical practice.

Self-regulated learning: why is it important compared to traditional learning in medical education?

Self-regulated learning has played an increasingly significant role in medical education over the last one to two decades. Medical educators have endeavored to ensure that the students are equipped to face the challenges of continued growth of medical knowledge. Here we enquire and reflect on various aspects of self-regulated learning including its strengths and weaknesses. We investigate how it could be incorporated with traditional teaching to bring the best out of the students and what students think about it.

Technical problems during laparoscopy: a systematic method of troubleshooting for surgeons.

BACKGROUND: Laparoscopic surgery has progressed rapidly since the early 1990s. For some surgical operations, it has become the standard of care to the extent where open surgery is sometimes looked down upon by some surgical colleagues as well as by patients. CURRENT STATUS: Despite this widespread adoption and acceptance, many surgeons struggle to understand how the laparoscopy stacks work despite having the skills to perform the operation. Most hospitals rely on operating theatre assistants to troubleshoot in the event of problems. This could be potentially unsafe for patients if laparoscopic vision or pneumoperitoneum is lost at a critical point of the operation. DISCUSSION: There are a number of approaches that have been published for troubleshooting laparoscopy stack. We explore and discuss some of them along with their advantages and disadvantages and how they relate to our methodology and approach. As a product of the discussion, we suggest a systematic way forward to troubleshooting laparoscopic tower equipment problems. CONCLUSION: The technical knowledge of surgeons and trainees varies widely in the area of laparoscopy-related troubleshooting. This systematic, practical algorithm would help and guide all surgeons to adopt a uniform approach, thereby improving patient safety.