Issue #5: November 16th, 2022
- Nour Atassi
- Dec 11, 2022
- 11 min read
“The only means of strengthening one's intellect is to make up one's mind
about nothing -- to let the mind be a thoroughfare for all thoughts.”
--John Keats
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This month’s surgeon spotlight is Princess Vera Gedroits.
The mechanism of postoperative ileus (POI) has been attributed to the inflammatory response in surgical trauma. To address this, electroacupuncture (EA) has been introduced by multiple studies as a treatment via inhibition of the vagal-adrenal pathway. Although systematic reviews have shown the potential of EA to recover GI function after surgery, no studies have evaluated the same circumstances with regards to laparoscopic bowel resection. In this multicenter randomized clinical trial, researchers aimed to assess the efficacy and safety of EA for POI in patients after laparoscopic surgery for colorectal cancer via the ERAS protocol. The patients were assigned to 4 sessions of EA or sham EA (SA) after surgery. The primary outcome was the time to first defecation with secondary outcomes including time of first flatus, first tolerance to semi liquid diet, first tolerance to solid food, and first ambulation.
Out of the 249 patients who were randomly assigned to the EA and SA treatment groups, the median time to first defecation was 76.4 (67.6-96.8) hours in the EA group and 90.0 (73.6-100.3) hours in SA group In the EA group compared with the SA group, the time to first flatus (median [IQR], 44.3 [37.0-58.2] hours vs 58.9 [48.2-67.4] hours; P < .001) and the tolerability of semi liquid diet (median [IQR], 105.8 [87.0-120.3] hours vs 116.5 [92.0-137.0] hours; P = .01) and solid food (median [IQR], 181.8 [149.5-211.4] hours vs 190.3 [165.0-228.5] hours; P = .01) were significantly decreased. Other secondary outcomes were no different between the groups. However, one of the limitations included the fact that this study is not generalizable for traditional open surgery. Another is the subjective nature of POI diagnosis which makes it difficult for comparisons. Despite these elements, the study demonstrated that EA will shorten the time of POI and lead to decreased risks of prolonged ileus after laparoscopic surgery. EA could be developed into the post-operative course in laparoscopic surgeries, but the research should be expanded beyond colorectal cancer treatment.
Only a third of the patients with small cell lung cancer (SCLC) are diagnosed at a limited and early stage. There has been a shift in current guideline recommendations which showed an overall survival rate greater than 50% in those who underwent surgical resection for early-stage SCLC. Previously, concurrent chemoradiation was the standard of care for these patients. As an important component in lung cancer surgery, lymph node (LN) dissection is also recommended for staging accuracy and surgical completeness; however, there is little data that supports this recommendation. In this retrospective study, researchers aimed to investigate the impact of LN dissection on patient survival and tumor recurrence, specifically in patients with cT1-2N0M0 SCLC. Out of 147 patients, 112 were designated into the LN dissection group, whereas 35 were placed into the LN sampling group. The main outcomes of this study were overall survival and recurrence-free survival at follow-up five years later. The authors also examined the outcomes for patients with (pN+) and without (pN0) pathologic nodal metastasis.
Patients in the LN dissection group had better overall survival in comparison to the LN sampling group (66.4% vs. 48.4%; P = 0.009) at five years postoperatively. This was also seen with the recurrence-free survival (63.5% vs. 37.6%; P = 0.003), the LN dissection group having a better recurrence-free survival in both pN0 (P = 0.05) and pN+ (P = 0.036) patients. Interestingly, those in the LN sampling group experience more local disease recurrence compared to those in the LN dissection group (42.9% vs 11.6%; P < 0.001). The authors found the overall nodal upstaging rate was 37.6%. With their findings, the authors conclude that LN dissection was associated with improved survival for patients cT1-2N0 SCLC who underwent surgical resection. However, there is a need for further studies relative to the necessity of LN dissection, which is addressed by the authors. Given that this study had a relatively small sample size, more studies should be done - whether it’s a multicenter or numerous single-center studies - to address this topic and provide fruitful validation regarding the current recommended guideline for the treatment of early-stage SCLC.
Laparoscopic cholecystectomy, rather than open cholecystectomy, has become the standard procedure for treating cholelithiasis due to the former’s lower risk of infection, shorter hospital stays, and speedier recoveries. The available literature shows that 2% to 15% of laparoscopic cholecystectomies are converted to the open procedure, which leads to increased numbers of infections, hospital stays, postoperative complications, and readmissions within 30 days. In this retrospective cohort study, researchers attempted to to determine the risk factors for switching from laparoscopic to open cholecystectomy. 263 patients whose laparoscopic cholecystectomies were converted to open cholecystectomy during surgery in the study group and 264 randomly selected patients in the control group. The results showed that the following factors were statistically significant in conversions from laparoscopic cholecystectomy to open: age (increases 1.05 times every year), sex (men is 2.44 times higher than women), neurological diseases (5.26 times greater), and diabetes (1.9 times greater). These results agree with previous studies’ findings. This study revealed the main risk factors that may increase the risk of conversion from laparoscopic to open cholecystectomy. This information can help surgeons to optimize care based on known risk factors for this conversion. This study was limited by differences in the homogeneity of sex and age between the study and control groups. Moreover, the study was performed in a single hospital, thus limiting the results’ generalizability. Future studies should take these limitations into consideration.
To pack or not to pack? Perianal abscess is a common surgical complication which traditionally has been treated with incision and drainage. However, the postoperative management of perianal abscess cavities does not have strong evidence regarding wound packing. Until now. In this multicenter, two-group parallel design randomized clinical trial, researchers aimed to investigate if not packing perianal cavities postoperatively were less painful than packing. 433 adults with a primary perianal abscess were followed for 6 months for postoperative management after incision/drainage. The primary outcome was mean pain score after surgical incision/drainage of the abscess. Patients who had postoperative internal wound packing reported higher scores of pain (38.2) than those without packing (28.2) (p<0.0001). Additionally, the occurrence of fistula-in-ano and abscess recurrence rates were low in both groups, without statistical significance (p<0.20) . Thus, this begs the question-- if packing increases pain and doesn’t significantly lower rates of fistula formation or recurrence, then why continue with the surgical dogma of internally packing a wound? Perhaps, it would be better to leave the wound to air and allow for continued natural drainage.
Subspecialties: Cardiothoracics
Stanford Type A Acute aortic dissection(AAAD) is one of the leading causes of morbidity and mortality. The use of Total Arch Replacement(TAR) and Frozen Elephant Trunk(FET) at zone 1 and/or zone 2 has played a pivotal role in increasing the outcome of AAAD. A retrospective study based on Japan with a study population of 50 focused on the benefits of TAR and FET in treating AAAD. It was found that average age of occurrence is 67(p<0.024),54%(p<0.088) patients were male,70%(p<0.711)of the study population have preexisting hypertension,46%(p<0.529) are current or ex-smoker followed by 28%(p<0.128) hyperlipidemia which are the primary risk factor for aortic dissection. During the surgery procedure, intraoperative findings do have significance which may impact the outcome of the study. Intraoperatively, in 66% (p<.000) bilateral axillary artery is the cannulation site,in 58%(p<0.309) aortic arch is the entry, in 66%(p<0.000) zone 2 is the distal anastomosis site, while other associated procedures are done along with TAR WITH FET in 8%(p<0.292) visceral arterial stent followed by 6% each of bowel resection and stoma in (p<0.405) along with explorative laparotomy (p<0.546), post operatively the in hospital mortality rate was 4% in TAR with FET while its 12% in TAR without FET(p<0.3310). In this study, visceral malperfusion among 11% patients is the cause for in-hospital mortality in patient who underwent TAR with FET ,14% patient who underwent TAR with FET suffered from permanent neurological deficit, deep sternal infection occurred in 6% of patient and 4% patient required life-long dialysis and no patient suffered paraplegia. Rapid advancement in the various surgical techniques have a direct impact in the outcome of disease courses OF AAAD. Patients undergoing TAR with FET for AAAD have survival rates of 87.9%,84.1% and 84.1% at 1, 2 and 3 years respectively.
In a nutshell this study reflects the pivotal role of TAR WITH FET in minimizing morbidity and mortality among patients of AAAD. The limitations can be considered as the study population is 50. So this study can be taken as a pilot study which will be helpful in setting a strong foundation for the future of surgical treatment of AAAD.
Subspecialties: Orthopedics
Injuries in the anterior cruciate ligaments (ACLs) are commonly reported within populations of athletes, which may cause severe disabilities even after treatment. Anterior cruciate ligament injuries may occur with concurrent injuries to the menisci as well as medial collateral ligaments and cartilage. The anterior cruciate ligament in particular is treated by undergoing arthroscopic reconstruction surgery. However, it was unclear whether a COL1A1 polymorphism, rs1107946, may play a role in causing higher prevalence rates for ACL injury. 200 Middle Eastern men who underwent arthroscopic ACL reconstruction surgeries were studied in a case- control study, and their COL1A1 genes were compared relative to a control group that did not have any history of ACL injuries. When analyzed using the Hardy-Weinberg principle, there was no significant difference between the prevalence of ACL reconstruction surgeries and the presence of COL1A1 rs1107946 polymorphisms within the studied athlete population. The study was significant in that it attempted to analyze the potential relationship between genes and ACL injuries in athletes, but a strong limitation to this was that its participants were only males of Middle Eastern origin. Study results may have been more relevant if the analyses included females or other athletes from diverse ethnic backgrounds.
SURGEON SPOTLIGHT OF THE MONTH
Princess Vera Gedroits
April 19, 1870 (or 1876) - March 1932
For this issue, we will take a look at the life and achievements of Princess Vera Gedroits, a Russian physician and author. Her strength through political instability and her contribution to the field of surgery were pinnacle to modern trauma and abdominal surgeries today. As Russia’s first military surgeon, Dr. Gedroits was heavily decorated in both her civilian and military lives. She was the first female professor of surgery in Russia, the first female military surgeon, and the first woman to serve as a physician to the Russian Imperial Court. Lastly, perhaps her most contribution to medicine in general, Gedroits was also the first to instill laparotomies for traumatic abdominal injuries.
Dr. Gedroits was an enigma of sorts; despite the magnitude of her achievements, not much is officially known about her. Limited records regarding Gedroits were published in English, so even her birth year is under debate. What we do know about Gedroits is that she was a descendant of Lithuanian royalty, and her wealthy background allowed her to complete education partially at home before attending school in St. Petersburg. She was arrested for taking part in left-wing revolutionary activities when she was sixteen, so as a result, she finished her medical education in Switzerland. Gedroits returned to Russia and officially obtained her title as a doctor after passing her medical exams in 1901.
The first position held by Dr. Gedroits as a physician is the appointed surgeon at the Maltsov Cement Factory in western Russia. In addition to performing surgeries, Gedroits implemented the installment of physiotherapy equipment and an x-ray machine at the hospital, both were state of the art equipment in her time when x-rays were discovered in 1985, less than a decade earlier. She treated 103 patients in her first year with only 2 deaths. Workers of the cement factory undertook physically exhausting labor that involved regular heavy-lifting, contributing to the weakening of the abdominal muscles that gradually developed into hernias. Gedroits focused most of her attention on abdominal surgeries with hernia repair, an experience that will benefit her and the field of surgery tremendously in the years that follow.
A couple of years after her position at the cement factory, Gedroits volunteered as a military surgeon for the Red Cross at the outbreak of the Russo-Japanese War. The war suffered immense casualties at both sides and is often mentioned as a premonition to the casualties that will occur in the subsequent war, WWI. Few records in English exist about Gedroits’ activity during the war. According to an unpublished 1997 British journal article by Dr. John Bennett, on September 26, 1904, Gedroits set up a field hospital at Mukden, present-day Shenyang in China. Her field hospital was not stationery, however. The field hospital was in fact a train with an operating car and five patient cars. This meant that the mobile hospital would come dangerously into the front lines to retrieve wounded soldiers. Although medical personnel are officially neutral, the surgical trains in motion are often not recognized; so they are still subsequently targeted by gunfire, risking the lives of medical personnel and volunteers. In this environment, Dr. Gedroits dared to perform interventions for abdominal wounds that were deemed inoperable by many of her counterparts in Western Europe. Gedroits stressed that early intervention was crucial in reducing the mortality of the wounded soldiers, specifically surgical attention within 3 hours of the abdominal wound. Because of her extensive experience in abdominal surgeries during her position at the cement factory hospital, she performed laparotomies for penetrating abdominal wounds with a high success rate. Her interventions were subsequently implemented into medical guidelines internationally.
Dr. Gedroits returned to Russia after the war and returned to her post as the chief surgeon at the factory hospital in 1905. She compiled and published a 57-page report with illustrations of her work in the war to submit to the Society of Military Doctors. Medical historians have since recognized that had others in the field paid attention to her publications, casualties during WWI could have potentially been reduced as her findings were published 10 years before the start of the war. In 1909, she was appointed as the attending physician in the Russian Imperial Court. However, during the February Revolution in 1917, Gedroits could not openly support the Russian Provisional Government as an employee of the Tsar. To remain neutral while respecting her friendship with the Imperial family, she returned to the battlefront as a military surgeon during WWI. She was sent to the front lines and was wounded during the demobilization after the Bolshevik Revolution. She recuperated and settled in Kiev with her long-time partner, Countess Nirod, for the remainder of her days.
Gedroits’ final days are somewhat tragic, and perhaps the reason why the world does not remember her despite her important contributions to medicine. Gedroits became a faculty of surgery in 1920 when the Kiev Medical Institute organized a surgery department, and subsequently became the department head of surgery in 1929. However, in the following year, she was removed from her post and denied a pension during the Soviet purge (Union for the Freedom of Ukraine trial). Despite her destabilization, she continued to work as a surgeon at the Intercession Monastery’s hospital and devoted the next two years into writing. Gedroit died in March 1932 of uterine cancer. She left her personal papers to her neighbors, Irina Avdiyeva and Leonid Povolotsky. Among the papers left behind was a letter from her professor, the Swiss surgeon Cesar Roux, advising his bequeathment of the Department of Surgery at the University of Geneva to Gedroits. During the purges of 1937-1938, Avdiyeva and Povolotsky’s apartment was raided. Upon the discovery of Gedroits’ letters, the couple were accused of imperialism and Povolotsky subsequently forcibly disappeared by the government.
Sources:
Bennett JD. Princess Vera Gedroits: military surgeon, poet, and author. BMJ. 1992;305(6868):1532-1534. doi:10.1136/bmj.305.6868.1532
https://www.bbc.com/future/article/20190418-the-princess-who-transformed-war-medicine
Віленський (Vilenskyi), Юрій (Yurii) (5 September 1996). "Незвичайне життя Віри Гедройц" [The extraordinary life of Vera Gedroits] (in Ukrainian). Kyiv, Ukraine: День.
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