Issue #15: November 23rd, 2024
- Keats Writers
- Dec 31, 2024
- 10 min read
Updated: Mar 1
Darkling I listen; and, for many a time
I have been half in love with easeful Death,
Call’d him soft names in many a mused rhyme,
To take into the air my quiet breath;
Now more than ever seems it rich to die,
To cease upon the midnight with no pain,
While thou art pouring forth thy soul abroad
In such an ecstasy
—John Keats, "Ode to a Nightingale," 1819
Assessing the Role of Pectoral Nerve Blocks in Postoperative Pain Management for Masculinizing Mastectomy Patients
By: Samantha Redden
Gender-affirmation surgeries are becoming increasingly common in the U.S., with masculinizing mastectomy being the most frequent procedure performed. Currently, over 1.4 million adults identify as transgender, and 25% of these individuals have undergone some gender affirmation surgery. However, managing postoperative pain while minimizing opioid use remains a challenge, particularly since substance use rates are higher among transgender individuals. Mastectomy for gender affirmation is distinct from other breast procedures, as each is tailored to the specific patient population, and they cannot be considered equivalent. Additionally, there is no data on the effectiveness of regional anesthesia in reducing pain or opioid consumption following masculinizing mastectomy. Therefore, this study aims to determine whether patients receiving a pectoral nerve block (Pecs block) report lower postoperative pain scores and require fewer opioids compared to those receiving general anesthesia alone. A randomized, double-blind, placebo-controlled trial was conducted between July 2020 and February 2022. Participants received either a Pecs block with ropivacaine or a placebo injection. Intraoperative and postoperative opioid requirements were recorded as morphine milligram equivalent (MME), and participants logged their pain scores for seven days after surgery. The primary outcome was the patient-reported postoperative pain scores, while secondary outcomes included opioid consumption during and after surgery and the time to discharge following the procedure. During the study period, 96 patients underwent bilateral masculinizing mastectomy; however, only 50 participants were enrolled, and ultimately, 43 were analyzed (27 in the intervention and 23 in the control group). The analysis concluded that there was no significant difference in intraoperative MME between the Pecs block and control groups (9.8 versus 11.1; P = 0.29). In addition, there was no difference in postoperative MME between the groups (37.5 versus 40.0; P = 0.72). Postoperative pain scores were also similar between the groups at each specified time point. In conclusion, a no-opioid approach may be more suitable for this surgery. The effectiveness of the Pecs block may vary from other oncological procedures due to differences in pain management, age group or other factors. The study’s findings, coupled with existing research, support a shift toward non-opioid pain management strategies. A multicenter approach in future research could enhance the generalizability of these results.
Surgical Strategies for Chronic Subdural Hematomas: Evaluating the Benefits of MMA Embolization
By: Riva Kelly
A subdural hematoma (SDH) is a collection of blood between the skull and the dura, the outermost covering of the brain. SDH develops with head trauma that causes shearing of tiny bridging veins in between the dura and skull. SDH can be acute, chronic, or acute on chronic in nature. Surgical evacuation is considered first line treatment as it provides immediate decompression, which ultimately relieves symptoms. In addition to surgical evacuation, it is thought that embolization of the middle meningeal artery (MMA) can have multiple benefits for treatment of chronic SDH. These include reduction in recurrence rates, prevention of hematoma enlargement, and more favorable outcomes. The MMA is one of the main blood supplies to the dura mater. Therefore, embolization of the MMA cuts off the blood supply, which prevents rebleeding. In this prospective randomized clinical trial, 35 patients with symptomatic chronic SDH were randomized into either the surgery alone or surgery with postoperative MMA. The primary aim was to investigate neurological outcomes and resource utilization between the two groups. The patients were evaluated at discharge, 4-6 weeks postoperatively, and at the last encounter when radiologic resolution was observed. Although at discharge, there was no statistical significance in the number of patients with neurological improvement in the surgery alone vs postoperative MMA group (56% vs 71%, p=0.29), this was not the case at follow-up. At 4-6 week postoperative follow-up, there was a statistically significant difference between the number of patients who showed neurological improvement in the surgery alone vs postoperative MMA group (33% vs 71%, p=0.03). Additionally, 39% of the surgery alone group required repeat surgery compared to only 6% in the postoperative MMA group (p=0.02). Moreover, the surgery alone group required more days of follow-up than the postoperative MMA group, which was statistically significant (205 vs 39, p=0.02). Given these study findings, surgical evacuation of chronic SDH in combination with postoperative MMA embolization shows significant neurological improvement and decreased resource utilization. A larger randomized clinical trial would be of great benefit to potentially incorporate postoperative MMA embolization as part of first line treatment for chronic SDH.
Grandma’s displaced 4-part proximal humerus fracture does not need surgery
By: Benjamin Crews
Proximal humerus fractures (PHF) are amongst the most common fractures in older adults, especially in those greater than 60 years old with osteoporosis. Non-operative management is typically recommended for non-displaced PHFs, while the management of displaced 3 or 4-part PHFs remains debated. Recently, studies have shown an increase in operative management for these fractures, especially with the introduction of locking plates (LP) that enhance fixation in osteoporotic bone. This multicenter, randomized 3-arm open-label, blinded endpoint RCT compared outcomes of PHFs managed with LP, hemiarthroplasty (HA), or non-operative with collar cuff. 150 patients older than 60 years old were enrolled in the study, and were divided into LP (n=49), HA (n=49), and non-operative (n=52) groups. Patients followed a standardized rehabilitation protocol, with assessments at 3, 6, 12, and 24 months. Outcomes were measured with the Disability of the Arm, Shoulder, and Hand (DASH), which ranges from 0-100 and requires > 10-point difference for clinical importance. At 24 months, the between-group differences in DASH were 1.07 points (95% CI (-9.5, 11.7), p = 0.97) between nonoperative and LP, 3.78 points (95% CI (-7.0, 14.6), p = 0.69) between nonoperative and HA, and 4.48 points (95% CI (-5.7, 15.4), p = 0.53) between LP and HA. The findings suggest that operative treatment (LP or HA) is not superior to non-operative management. While this study began before the reverse total shoulder arthroplasty emerged, it reinforces non-operative care as a viable option for displaced 3- and 4-part PHFs, with surgery remaining an option if fractures progress to non-union or malunion.
Is robotic surgery a safer option for diabetic women undergoing hysterectomy for endometrial cancer?
By: Kelsey Lane
Endometrial cancer is a common gynecologic cancer, and hysterectomy is a primary treatment option. For women with diabetes, surgical outcomes can be more complicated due to associated health risks. Understanding the differences in short-term outcomes between robotic and laparoscopic approaches can help guide surgeons in selecting the safest and most effective procedure. Using the US Nationwide Inpatient Sample, this retrospective, population-based observational study analyzed outcomes in 57445 diabetic women undergoing robotic or laparoscopic hysterectomy for endometrial cancer. The primary endpoint was differences in short-term outcomes– length of stay, unfavorable discharge disposition, total hospital costs, and postoperative complications– between robotic vs laparoscopic surgery. The robotic approach was associated with shorter hospital stays (0.46 fewer days, 95% CI: −0.57, −0.35) and less unfavorable discharge (adjusted OR = 0.63, 95% CI: 0.46, 0.85) compared to the laparoscopic approach. However, robotic surgery was also associated with higher costs (6129.93 greater USD; 95% CI: 4448.74, 7811.12) than laparoscopic surgery. There was no statistical difference between postoperative complications between robotic vs laparoscopic approach. The findings suggest that robotic hysterectomy may offer better short-term outcomes for diabetic women with endometrial cancer, although the increased cost should be considered.
Chiari I Malformation: Displacement of the Cerebellar Tonsils
By: Ryan Liengswangwong
In addition to the malformation of the cerebellar tonsils, Chiari I malformation also involves the inferior displacement of the structures through the foramen magnum. When symptomatic, the patient may experience headaches and neck pain. This may emanate from the suboccipital region, potentially exacerbated by coughing. Generally, the sagittal plane with MRI provides optimal visualization of the malformation, illustrated in the above image. However, to diagnose Chiari I malformation, the cerebellar tonsillar position is measured. If the inferior displacement exceeds 6 millimeters, the diagnosis of Chiari I malformation is supported. If the patient has been diagnosed with Chiari I malformation and becomes symptomatic, the treatment option is surgical decompression at the posterior fossa region.
Sources:
Article: Gaillard F, Abu Kamesh M, Sharma R, et al. Chiari I malformation. Reference article, Radiopaedia.org https://doi.org/10.53347/rID-1111
Image: Gaillard F, Chiari I malformation. Case study, Radiopaedia.org https://doi.org/10.53347/rID-2592
Additional Reading: Al Kabbani A, Yap J, Gaillard F, Cerebellar tonsillar position. Reference article, Radiopaedia.org https://doi.org/10.53347/rID-71843
From Battlefield to Operating Room: The Journey of Edoardo Bassini and the Birth of Hernia Repair
By: Michael Yacoub
Dr. Edoardo Bassini (1844 - 1924)
The mindset of a soldier who chooses to go to war is driven by a strong sense of duty, patriotism, and belief in the cause they are fighting for. They undergo rigorous training, face moral dilemmas, and grapple with the human cost of war. They willingly leave behind the normalcy of civilian life, everyday conveniences, personal aspirations, and loved ones. It is inspiring to consider that such a path would be chosen by the surgeon who would later develop the first successful hernioplasty.
Edoardo Bassini was born to a prosperous land-owning family in Pavia, Italy, in 1844. He attended university in nearby Milan, graduating in 1866 with a degree in medicine. Soon after graduation, he abandoned medicine to enlist as a common infantryman in Giuseppe Garibaldi's guerrilla militia. In the mid-1800s, the Italian peninsula was a politically fragmented conglomeration of states with a feudalistic view of government, while the rest of the world had moved on to revolutionary ideas focused on freedom and equality. Bassini, like much of the professional class on the Italian peninsula, was captivated by the idea of a unified Italian political state—to the extent that he was willing to fight for it. In hand-to-hand combat against superior conservative forces, Bassini sustained a deep bayonet wound to the right lower quadrant.
Forced into a French field hospital to recover, Bassini’s wound became infected and brought him near-death. His condition improved after he made an enterocutaneous fistula—a connection between his bowel and skin. This drained fecal output for several months before closing, relieving him of his septic condition. Bassini was discharged and transported back to Pavia, where he came under the care of his soon-to-be mentor, Luigi Porta. Once fully recovered, Bassini was appointed second assistant to Porta. In 1873, at Porta’s suggestion, Bassini traveled across Europe to learn from the great surgeons of his era.
With newfound knowledge, Bassini returned to Italy inspired by the possibilities of surgery. In 1874, Bassini was made Porta’s first assistant, a position that led to an 1877 appointment as the head of surgery at Spezia. It was here that Bassini’s careful dissections of the groin region resulted in an understanding of the anatomy that would make the first reliable cure for inguinal hernia possible.
To fully appreciate the complexity of Bassini's contribution to surgery, it is important to understand the inguinal canal. The inguinal canal exists between two openings– the deep inguinal ring and the superficial inguinal ring– within the anterior abdominal wall. The canal is cone-shaped, with the deep ring having a smaller diameter than the superficial ring. The deep ring is a lateral hiatus within the transversalis fascia, and the superficial ring is a medial hiatus within the external oblique fascia. The canal is bordered anteriorly by the skin, superficial fascia, and the external oblique aponeurosis. The posterior wall is bounded by the transversalis fascia, extraperitoneal tissue, and parietal peritoneum. Additionally, the conjoint tendon, composed of the transversus abdominis and internal oblique aponeurosis, is located on the medial two-thirds of the posterior wall. The roof is formed by the arching fibers of the internal oblique and transversus abdominis, while the floor is formed by the grooved surface of the inguinal ligament.
Bassini's repair essentially tightened the inguinal canal by reconstructing the posterior wall and floor. This can be thought of as rolling a paper cone in on itself. Bassini accomplished this by creating a relaxing incision in the conjoint tendon and suturing it to the inguinal ligament all the way to the deep inguinal ring. In this way, the conjoint tendon, which previously accounted for two-thirds of the posterior wall, now became the majority, if not all, of the posterior wall. After dissecting into the inguinal canal by incising the external oblique aponeurosis at the superficial inguinal ring, preserving the spermatic cord (if present) and ilioinguinal nerve, and reducing the contents of the hernia sac prior to suture-ligating the associated parietal peritoneum, Bassini performed this reconstruction to effectively end years of futility in hernia repair.
By 1890, following his first herniorrhaphy on December 23, 1884, Bassini had completed 262 herniorrhaphies in 216 patients. He recorded a 97% non-recurrence rate in his patients at 4.5 year follow-up. This was staggeringly better than the other attempts at hernia repair at this time, which only attempted to plug the inguinal canal to prevent recurrence.
The Bassini repair has had a lasting impact on hernia surgery and continues to be used and appreciated by surgeons around the world. It represents an important advancement in the understanding and treatment of inguinal hernias, benefiting countless patients over the years. Bassini's careful dissection and observation elucidated the distinction between direct and indirect hernia defects and described the preperitoneal plane, which has proved to be important in the development of modern preperitoneal mesh repair techniques. At the end of his surgical career, Bassini retired to his farm, where he took an active interest in agriculture and horse breeding until his death at the age of 80.
Sources:
1. Booth J, Keshava H, Carneiro H, et al. Inguinal hernia repair: Enduring influence of Edoardo Bassini. Am J Surg. 2018;215(4):666-673.
2. Thomas A, Rogers A. Edoardo Bassini and the wound that inspires. World J Surg. 2004;28(11):1060-1062. doi:10.1007/s00268-004-7466-5.
3. Office of the Historian. Italian Unification, 1815–1871. U.S. Department of State, Office of the Historian. Accessed August 1, 2024. https://history.state.gov/countries/issues/italian-unification
4. Open Inguinal Hernia Repair - StatPearls - NCBI Bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK459309/
5. Abernathy CM. Abernathy's Surgical Secrets. Chapter 58, pp. 250-256.
6. Tan WP, Lavu H, Rosato EL, Yeo CJ, Cowan SW. Edoardo Bassini (1844-1924): father of modern-day hernia surgery. Department of Surgery Gibbon Society Historical Profiles. Paper 20. Published November 1, 2013.
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