Issue #6: December 21st, 2022
- Nour Atassi
- Dec 21, 2022
- 14 min read
“When I have fears that I may cease to be
Before my pen has gleaned my teeming brain,
Before high-pilèd books, in charactery,
Hold like rich garners the full ripened grain;
When I behold, upon the night’s starred face,
Huge cloudy symbols of a high romance,
And think that I may never live to trace
Their shadows with the magic hand of chance;
And when I feel, fair creature of an hour,
That I shall never look upon thee more,
Never have relish in the faery power
Of unreflecting love—then on the shore
Of the wide world I stand alone, and think
Till love and fame to nothingness do sink..”
--John Keats
HAPPENINGS THIS MONTH:
Please email us if you are interested in sharing your surgical research!
We are looking for students interested in OB/Gyn to become a subspecialty writer! Please email us if you are interested!
Are you good with your Radiology? Want to be part of our educational team? Please email us if you are interested!
This month’s surgeon spotlight is William Stewart Halsted.
Esophageal variceal bleeding is the most common fatal factor for patients with cirrhotic hypertension. Current treatments include transjugular intrahepatic portosystemic shunting (TIPS), open splenectomy and azygoportal disconnection (OSD), and endoscopic variceal ligation (EVL). OSD has been shown to reduce varix pressure secondary to the azygoportal disconnection, while EVL has been shown to lessen the surface area of the varices, but has no effect on varix pressure. Therefore, combining OSD and EVL could potentially lower the risk of esophagovariceal rebleeding. Of note, laparoscopic splenectomy and azygoportal disconnection (LSD) with vagus nerve preservation has largely replaced OSD due to its improved postoperative recovery and reduced trauma. In this randomized clinical trial, cirrhotic patients were divided into 2 interventional groups in order to determine if LSDL was safe and could stop EVL compared to single LSD.
The first interventional group underwent vagus nerve preserving LSD without intraoperative ligation (n=44), while the second group underwent vagus nerve preserving LSD with intraoperative ligation (LSDL) (n=44). The key procedural difference was that if a diameter of esophageal varices > 5 mm was found in the LSDL group, EVL was performed. The EVR rate was significantly lower at 4 months postoperatively in the LSDL group (1 patient) compared to the LSD group (8 patients). Additionally, the reduced EVR rates in the LSDL group were seen postoperatively at 1-month (2 patients), 3 months (3 patients), 6 months (6 patients). At the one-year follow-up, patients who received EVL due to varices diameter > 5mm had a significantly lower EVR rate than those who underwent LSD without intraoperative ligation.
This study shows strong positive results when a combination approach is taken to mitigate the risks of EVR. As such, patients who have lower EVR risk will have additional benefits such as fewer hospital stays, decreased risk of death, and decreased medical burden. There is great potential for the future of this operation based on this study. However, it needs to be recreated with a larger sample size and inclusion of parameters for patient quality of life.
The use of antiseptic solutions and antibiotic prophylaxis to prevent surgical site infections (SSIs) is not a new phenomenon. Previous trials comparing alcohol-chlorhexidine to iodine-based solutions have demonstrated alcohol-chlorhexidine proved to be a better choice. However, this comparison has not stretched to specifically cover laparoscopic gynecological procedures. In this double blind randomized clinical trial, researchers compared the rates of different types of SSIs amongst patients undergoing nonmalignant gynecological laparoscopies.
A total of 640 patients were included in final analysis and were randomized into a 1:1:1 ratio to one of the three preoperative antiseptic skin solution groups: Alcohol-chlorhexidine solution (Alc-CHX; 210 patients), aqueous-povidone-iodine solution (Aqu-PVP-I; 214 patients), and alcohol-povidone-iodine (Alc-PVP-I; 216 patients). The patients were instructed to follow-up with a physician one week and four weeks after surgery. Based on the CDC infection criteria, the physician assessed and documented the presence/absence of infection at the surgical site and findings relating to organ or space infections. The overall rate of any SSI, port-site infection, organ/space infection were 16.3% Alc-CHX, 10.2% Aqu-PVP-I, and 6.6% Alc-PVP-I. There was no statistically significant difference across the different treatment groups. The findings indicate that none of skin preparation solutions proved to be a superior choice in reducing the rate of SSIs, port-site, and organ/space infection for patients undergoing gynecological laparoscopies. Though the general rate of SSIs were higher (especially at the incisional port site) than the researchers expected, it was still lower than in non-gynecological laparoscopic surgery trials.
The result does make one wonder why previous studies found lower rates of SSIs with Alc-CHX. Those previous studies focused on open surgeries, which may confer a higher risk of infections when compared to laparoscopic procedures. The findings could also be impacted by the type of surgery (abdominal vs non-abdominal surgery) performed. This study suggested that a higher body mass index and older age increase risks of specific types of infections. Future studies can further explore how those risk factors as well as antibiotic prophylaxis protocols affect the outcome of open versus laparoscopic gynecological surgery.
Historically, patients with chronic constipation have reported dissatisfaction with anti-reflux surgery (ARS) outcomes. This suggests that there may be a potential link between colonic dysmotility and ARS outcomes. Until now, there was no objective method in place to obtain data for analyzing this hypothesis.This retrospective study is the first of its kind to use an objective measure of hindgut physiology with a wireless motility capsule (WMC) to evaluate colonic dysmotility and outcomes after ARS.
WMC is an ingestible capsule that captures the pH, temperature, and pressure gradients within different regions in the gut. WMC was used prior to ARS. ARS approaches were either Nissen fundoplication or magnetic sphincter augmentation. The duration of the test was measured from the time of ingestion of the WMC to the time of loss of signal between the capsule and monitor. Upon WMC completion, all patients underwent ARS and had follow-up for at least 6 months postoperatively. A favorable outcome consisted of resolution of the main reflux symptom and freedom from antisecretory medications.
Patients who did not achieve favorable outcome criteria had significantly longer median whole gut transit times [p=0.024]. Patients with delayed colonic transit time (>59 hours) were more likely to have postoperative bloating and constipation. Patients with unfavorable outcomes had higher peak colonic pH measurements. The main finding of this study was that colonic transit times were significantly longer in patients who did not achieve a favorable ARS outcome. Though this study provides valuable information, it is important to note its limitations-- limited sample size and lack of randomization. Additionally, WMC was validated in a study with healthy individuals without any changes in temperature or pH. This is quite the contrast with the use of WMC to detect the changes in temperature and pH throughout the various bowel segments. While WMC can be helpful in determining which patients are likely to have less favorable ARS outcomes, it should not be used to determine surgical candidacy but rather to educate patients on realistic expectations and risks.
Genital gender-affirming surgery (GAS) such as vaginoplasty or phalloplasty, is a huge element of gender affirmation, but one large issue patients can have boils down to is access. Many GAS procedures require highly specialized surgeons located in high-volume medical centers. Recent studies have only found 61 surgeons within only 20 states will offer GAS, adding a miniscule geographical feature to the dilemma. But how impactful is location on a patient seeking GAS? In this cross-sectional study, researchers utilized insurance data in order to estimate the out of pocket (OOP) and total costs for GAS depending on state of residence and how these increased barriers can increase postoperative complications and interrupt continuity of care.
Previously collected insurance data of vaginoplasty and phalloplasty patients aged 18 to 64 years were identified, and their surgeries were separated based on state residency status. There were 176 patients who received vaginoplasty operations, and the median out of pocket (OOP) cost was $2079 for residents and $3336 for non-residents. There were 72 patients who received phalloplasty operations and the median OOP cost was $854 for residents and $2720 for nonresidents. One of the other stand-out results, is that those seeking out of state gender affirming operations were more likely to be from the South, indicating a geographic need for specialized surgeons in that area. It comes as little surprise that patients from southern states hold the short end of the stick in this matter. The results of this paper show how local poor attitudes towards transgender and gender diverse people can lessen the quality and availability of appropriate care in the surrounding area. These results can also be tied to the lack of specialized surgeons willing to work in the South due to the current socio-political climate, leaving these patients with no other option but to further stretch their wallets to pay the price of being true to themselves. This conversation is important if we want to ensure transgender and gender diverse patients of lower socioeconomic status can get the same standard of treatment and post-surgical recovery afforded to wealthier patients. This conversation can also further shed light on how these same individuals are more likely to suffer in states with more hostile social and political climates.
Subspecialties: Urology
Surgical reconstruction is often a viable option for urologic pathologies, especially for hypospadias and urethral strictures. Tissue engineering has arisen as a potential workaround for a lack of autologous tissue for reconstruction. Due to issues with previous methods, researchers have attempted to approach tissue engineering with mesenchymal cells to form an extracellular matrix, allowing tissues without exogenous biomaterial to be produced. These techniques required the use of dermal fibroblasts as urethral substitutes which had higher mechanical features. Adding in vesical fibroblasts allowed the urethral markers to match more with native tissues than you would see with dermal fibroblasts. Now it is important to specify that the question lies in what specific composition of dermal and vesical fibroblasts is the perfection mix. Specifically to serve as a means to create tissue that can be used in these reconstructive urological surgeries. The goal of this study was to ascertain whether the hypothesis of combining dermal fibroblasts and vesical fibroblasts in-vitro fertilization would work to create a substitute featuring structural and functional properties. The flat urethral tissue’s strength was increased by the presence of dermal fibroblasts, but did reduce the number of polysaccharides and had no impact on the urothelium’s pseudo-stratification. At the conclusion of the experiment, the ratio of 80-90% of vesical fibroblasts mixed with dermal fibroblasts showed the most optimal mechanical properties in the substitutes as they had almost-native barrier function relative to native counterparts. The substitutes lacked problematic issues of urothelial markers, indicating this substitute could be very useful in the context of urologic surgical reconstruction as a tissue. The experiment concluded that the optimal following experiment should be on utilizing a rabbit model of urethral replacement with in-vive implantation.
Subspecialties: Cardiothoracics
There is controversy in the timing of peripheral catheterized cardiopulmonary bypass (CPB), a device which serves the functions of the lungs and heart during surgery, ensuring proper oxygenation of the body. Early peripheral CPB (prior to surgery) compresses the cardiovascular structures and creates a safety net through better control of hemorrhage and hemodynamics in case of accidental injury. Though, some surgeons prefer late peripheral CPB (post-surgery) in order to avoid the heparization normally required in early CPB. Additionally, dissection off pump can be advantageous in multicomponent cases. But with modern CT scans, maybe an algorithm can be utilized to stratify patients into categories for decreased morbidity and mortality rates. In this retrospective study, the researchers aimed to evaluate the current practice and outcomes in preoperative cardiac surgery utilizing re-sternotomy, with a particular focus on early vs late implementation of CPB.
7,640 Patients were stratified into those who received early (n=755) and late CPB (n=5872). Each individual was also placed into high anatomic risk (n=563), low anatomic risk (n=5969), and high physiologic risk (n=95). Anatomic risk was based on CT imaging showing sternal adherence of bypass grafts crossing midline, ascending aorta adherence to the sternum, and pseudoaneurysm of the aorta within close proximity of the sternum. Any of the prior was placed into high anatomic risk. Physiologic high risk required early CPB due to hemodynamic instability or collapse before redo sternotomy (these patients were excluded from CPB stratification because of non comparable outcomes).
The most common re-operative procedures were aortic valve replacements (n=3611), CABG (n=2029), and aortic root or arch surgeries (n=1061 and n=527, respectively). Of these procedures, early CPB were more likely to receive aortic valve replacement or aortic surgery. Late CPB were more likely to undergo CABG or mitral/tricuspid valve replacement. Mortality rates were 3.5% overall, 4.1% in all early CPB, and 3.5% in all late CPB. Anatomic high risk mortality rates of early CPB were 2.8% and 3.8% for late CPB. The low anatomic risk mortality rates were 3.5% and 2.1% for early CPB and late CPB, respectively. High anatomic risk only saw greater intraoperative transfusion rates in early compared to late CPB (p=0.009) but no significance between other factors. Anatomic low risk observed fewer major re-entry and dissection injuries (p=0.03), shorter myocardial ischemic times (p=0.04), and less atrial fibrillation (p=0.05) in early CPB with greater intraoperative and postoperative blood transfusions (p=0.002).
The same team published an article in 2008 on this matter. Since then, they have incorporated the use of CT imaging stratification with each reentry case and successfully observed a decrease in mortality and morbidity, suggesting the use of CT scans to be quite beneficial. Based on the results, an algorithm was proposed as to when CPB should be administered . It is suggested early vs late CPB should be determined by anatomic risk, specific procedure, and ultimately the surgeon’s preference. Though, this was observed at a technical modern hospital with a team of highly specialized individuals. It would be interesting to see other institution’s data on the subject. For those with similar or greater results, what does their algorithm look like? And those with lower success rates, I would like to see if improvement can be achieved with the proposed algorithm here.
Subspecialties: Orthopedics
Ankylosing spondylitis (AS) is a disease that causes characteristic inflammatory back pain and affects axial and sacroiliac joints. Additionally, many patients exhibit osteoporosis and subsequent stress fractures, especially in the thoracolumbar region. As it stands, nonsurgical treatment approaches are safer than surgical corrections for thoracolumbar fractures.
In this retrospective cohort study, surgical interventions for thoracolumbar fractures in AS patients (TLFAS) were evaluated. 47 TLFAS patients were enrolled. There were 26 patients in the percutaneous long-segment internal fixation group, and 21 patients in the open fixation with long-segment screws. Various outcome variables were measured both at hospital admission (baseline) and at follow-up (6 month and 12 month). Patients in the percutaneous group had significant improvements in operative duration, blood loss and bed rest duration compared to the open group (p<0.05). Although both surgical approaches were successful, the percutaneous group had more positive results overall. In conclusion, the percutaneous approach should be considered first for TLFAS surgery instead of the open. However, a larger sample size is needed to allow for proper generalization of results.
Subspecialties: Neurosurgery
Lumbar spinal stenosis is a condition characterized by pain and stiffness in the lower back, with visible narrowing of the spinal canal on imaging. Studies suggest more successful clinical outcomes with surgery versus the non-surgical approach in adults. The standard has been an open laminectomy with a posterior decompression at the level of the stenosis. However, in the last few decades, less invasive procedures have been introduced. This begs the question–which is the most effective surgical method to apply in the management of lumbar spinal stenosis?
In this randomized clinical trial, the three most commonly used surgical approaches (unilateral laminotomy (UL) with crossover, bilateral laminotomy (BL), and spinous process osteotomy (SPO)) to compare effectiveness in treating lumbar spinal stenosis. Over the course of 4 years, 437 patients (53% men) with lumbar spinal stenosis without degenerative spondylolisthesis were enrolled. As a randomized clinical trial with a parallel design, patients were randomly assigned to undergo one of the three previously mentioned interventions. Of the included patients, 146 were randomized to UL with crossover, 142 to BL, and 149 to SPO. The primary outcome was the mean change from baseline to 2-year follow-up with a >30% reduction in the Oswestry Disability Index (ODI; range 0-100). As a result, the UL with crossover group had a mean change of −17.9 ODI points (95% CI, −20.8 to −14.9), the BL group had a mean change of −19.7 ODI points (95% CI, −22.7 to −16.8), and finally, the SPO group had a mean change of –19.9 ODI points (95% CI, −22.8 to –17.0). According to this, there were no significant differences between groups, except for a relatively longer procedure duration in the BL group. In conclusion, all three surgical methods were considered equally effective, only differing in surgical time. Even though this clinical trial yielded positive results, it did not compare UL, BL, SPO to the open laminectomy. This begs the question on whether a further comparison should be implemented as open laminectomy is not generally used at most centers. Perhaps a larger sample size should be utilized in future investigations to verify the application for clinical decision making.
SURGEON SPOTLIGHT OF THE MONTH
William Stewart Halsted
September 23, 1852 – September 7, 1922
In this month’s issue, we will take a look at the turbulent, but brilliant life of the infamous Dr. William Stewart Halsted. Dr. Halsted gained much of his notoriety from his approach to medical education, radical at his time, and his personal struggles with addiction, However, his contributions as a surgeon cannot be ignored as they are heavily integrated into the current standard of practice in General Surgery. This was a man whose greatest strength and weakness was his academic curiosity of medicine, which led him to both acclaimed discoveries and his personal struggles with addiction.
One of Halsted’s contributions to medicine was the introduction of the hospital chart in 1874 after graduating from the Columbia University College of Physicians and Surgeons. Although mundane to us in modern medicine, it proved to be an instrumental tool in tracking a patient's recovery and overall health while in the hospital. From his time in New York in 1880 to 1885, Halsted performed many medical feats that were considered bold in his time. In 1881, Halsted performed the first successful emergency blood transfusion secondary to obstetric hemorrhage recorded in the United States. He also performed the first cholecystectomy in the United States on his mother in 1882 with her complete recovery. Outside of surgery, he pioneered the practice of antiseptic surgery at Bellevue Hospital and transformed the classical teaching of medical education into a more hands-on approach.
In 1884, Halsted’s natural curiosity of the medical arts led him to the report made by Dr. Karl Koller that described the anesthetic properties of cocaine. Halsted, his students, and his colleagues experimented with cocaine to demonstrate its property as a safe local anesthetic when injected or applied topically. Unfortunately, many members of the cohort ultimately succumbed to the addiction of cocaine after this incident, including Halsted himself. His battle with addiction became an unfortunate struggle that ultimately led to the end of his medical career in New York.
Dr. Halsted eventually admitted himself into the Butler Sanatorium to address his addiction. When he was discharged in 1886, he joined William Welch as one of the four founders of Johns Hopkins Hospital. While at Johns Hopkins, Halsted’s notoriety further increased with his establishment of the first formal surgical residency program for postgraduate medical training in 1889. In his system of an internship followed by a period as assistant resident and a final stage as house surgeon, Halsted trained many prominent figures of surgery including Harvey Williams Cushing and Walter Dandy, the founders of neurosurgery, and Hugh H. Young, the founder of urology as a specialty. Despite producing many talented surgeons, the system is not without critique, and some historians suggest that Halsted’s rigid system of hierarchy with streamlined roles for efficiency was perhaps a way for him to hide his physical and mental decline due to his struggles with addiction.
While at Johns Hopkins, Halsted’s most well-known contributions to the surgical arts include the introduction of rubber gloves as common practice for surgery and his approach for radical mastectomy for breast cancer, which significantly reduced the rates of recurrence by removing lymph nodes surrounding the tumor. Halsted made further advancements in biliary, thyroid, and abdominal aneurysm surgeries. Other advancements that Halsted was responsible for include introduction of the Halsted Mosquito hemostat and the Halsted (mattress) suturing technique.
In his later years with Johns Hopkins, many noted that Halsted evolved from the bold and daring physician to a cautious surgeon who is meticulous to a fault. Contrary to how he approached medicine while in New York, Halsted stressed the importance of preserving the most original organs in surgery. Some critics have speculated that Halsted used the guise of attention to detail and conservative surgical principles to hide his further declining fine motor capabilities due to his addiction. Whether that is truly the case, it is all mere speculation, and we may never know Halsted true intentions and the true extents of damage caused by his personal struggles. What is evident to this day is the legacy Dr. Halsted left behind, and how much of his work are still the foundations of various standards in medicine from residency training to suturing techniques.
Sources:
Wright Jr. JR, Schachar, NS. Necessity is the mother of invention: William Stewart Halsted’s addiction and its influence on the development of residency training in North America. Can J Surg. 2020;63(1):E13-E19. Published 2020 Jan 16. doi:10.1503/cjs.003319
Osborne, Michael P. “William Stewart Halsted: his life and contributions to surgery.” The Lancet. Oncology vol. 8,3 (2007): 256-65. doi:10.1016/S1470-2045(07)70076-1
Gerald, Ember (2011). "Genius on the Edge: The Bizarre Double Life of Dr. William Stewart halsted". Anesthesiology. 114 (6): 1496–1497. doi:10.1097/ALN.0b013e318216e9fa. PMC 2898614.
Halsted, WS (1893). "The radical cure of inguinal hernia in the male". Annals of Surgery. 17 (5): 542–56. PMC 1492972. PMID 17859917
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