Issue #8: April 26th, 2023
- Nour Atassi
- Apr 26, 2023
- 12 min read
Updated: Apr 27, 2023
Sonnet To Sleep
O soft embalmer of the still midnight,
Shutting, with careful fingers and benign,
Our gloom-pleas’d eyes, embower’d from the light,
Enshaded in forgetfulness divine;
O soothest Sleep! if so it please thee, close,
In midst of this thine hymn, my willing eyes,
Or wait the Amen, ere thy poppy throws
Around my bed its lulling charities;
Then save me, or the passed day will shine
Upon my pillow, breeding many woes;
Save me from curious conscience, that still lords
Its strength for darkness, burrowing like a mole;
Turn the key deftly in the oiled wards,
And seal the hushed casket of my soul.
–John Keats, 1819
HAPPENINGS THIS MONTH:
Congratulations to everyone in Match 2023!
We have a new logo!
For this upcoming 2023-2024 school year, we will have a brand new team of writers. We will be announcing our decisions early May. Await our email!
We are proud to announce our two new board members Michelle Sener and Yu-Yun Chen, both Incoming PGY-1s.
Want to hear more about another surgical subspecialty? Let us know!
Want help on your personal statements? In coming months we will be offering our services as editors and residents to edit and advise on personal statements for Match 2024. If you are interested contact us. More information to follow in coming months.
This issue’s Surgeon of the Month is Dr. René Gerónimo Favaloro
Surgical management for anal fistulas is often complicated by high-type fistulas. Simplistically speaking there can be two types: high and low. In low fistulas, the internal orifice of the fistula will begin below the puborectalis and the track will pass through minimal or no sphincter muscle fibers. In a nutshell, the fistula is close to the skin for surgical access. However, a high fistula the internal anal orifice will begin above the puborectalis muscle and the track will pass through or above a moderate or large quantity of muscle fiber. This trajectory of fistula makes surgical management tricky and is commonly further away from the skin, with 30% involving the external anal sphincter. So then, what can be done for these patients in the long term? Endorectal advancement flap (ERAF) and ligation of the intersphincteric fistulous tract (LIFT) have both been treatment options for high fistulas. But what is better?
In this prospective randomized control trial, patients with high-type anal fistulas were randomized into ERAF or LIFT treatment groups and followed for 24 months to pinpoint the outcomes and success rate of both treatments. Regardless of treatment, they all underwent the same preoperative regimen, including a liquid diet, an enema, and IV antibiotics. Monitored outcomes included: operative duration, healing time, pain, complications, and continence parameters were observed, and, lastly, quality of life after 6 months (Cleveland Global Quality of Life score).
At the conclusion of the study, the researchers observed the following improved parameters for LIFT vs ERAF: shorter operative time (46.4+9.3 vs 89.3+10.9; p<0.001), and better healing rates, pain scores, and quality of life in the LIFT group compared to ERAF. However, both groups also had patients who did not achieve adequate healing parameters and required another operation. One limitation is the exclusion of patients with inflammatory bowel disease. It’s hard to ascertain if that patient population would also have similar benefits with LIFT. Additionally, fistula dimensions were not emphasized. Perhaps, an analysis of the size/length of fistulas could offer more insight into treatment approaches. Needless to say, high type in-ano fistulas continue to be a challenge, and further studies are needed to provide recommendations.
Surgeons are often faced with the choice between laparotomy or peritoneal drainage in treating children diagnosed with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). But, choosing the right treatment may depend on the preoperative diagnosis being NEC or IP. Unfortunately, nearly 50% of low-birth weight infants inflicted with NEC or IP die. Amongst infants that survive, 60% develop neurodevelopmental impairment (NDI) and 20% cerebral palsy. In this prospective, randomized clinical trial, infants with suspected NEC or IP were placed in initial laparotomy versus peritoneal drainage groups and compared. The primary outcome was death or NDI at 18-22 months.
After the initial laparotomy, 69% of infants suffered death or NDI at 18-22 months, compared to the 70% after peritoneal drainage. Out of the 94 infants with a preoperative diagnosis of NEC, 69% died or developed an NDI after laparotomy, compared to the 85% of infants after drainage. Out of the 201 infants with a preoperative diagnosis of IP, 69% died or developed an NDI after laparotomy, compared to the 63% of infants after drainage. In infants with a preoperative diagnosis of NEC, 46% died at 18-22 months vs 21% for infants diagnosed with IP. The mortality for patients diagnosed with NEC was 40% with initial laparotomy versus 51% with drainage. In infants with a preoperative diagnosis of IP, 23% died after initial laparotomy versus 19% with initial drainage. Based on the results, there was no overall difference in death or NDI rates between initial laparotomy versus peritoneal drainage. Future studies can focus on factors attributable for differences in favorable outcomes in infants with NEC versus IP. It is worth mentioning that the results are not definitive.
Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a treatment option for peritoneal metastases. But, there is no standardized CRS-HIPEC protocol for a specific malignancy, and it varies amongst institutions. Typically, CRS-HIPEC involves an omentectomy and is done in the absence of visible omental metastasis. There is a debate in regard to the necessity of omentectomy; therefore, researchers wanted to evaluate the rate of occult omental metastases in patients undergoing CRS-HIPEC. In this single-center, retrospective, cohort study CRS-HIPEC procedures were divided into greater omentectomy (OM) and those that did not (NOM) to determine the rate of omental metastasis (OHOM). Additionally, researchers wanted to investigate both the morbidity of omentectomy and examination of omental recurrence after CRS-HIPEC.
Of this, a greater omentectomy was performed in 578 CRS-HIPEC procedures (105 patients did not have an omentectomy). In 43 patients in the non-omentectomy group that had a residual omentum, it was noted that 24 of those patients had developed recurrent disease. Of these 24 recurrences, nine occurred within the residual omentum, whereas fifteen were extra-omental. In the omental resection group, 72 patients had a grossly normal appearing omentum in contrast to 23 of them having occult histologic omental metastasis. In those who underwent omentectomy, there was no difference in morbidities, such as the return of bowel function, ileus, and 60-day complications, between the two groups. Given that there was no increase in morbidities and that histologically occult metastasis was present in a third of patients undergoing omentectomy during CRS-HIPEC, the authors conclude that omentectomy should be performed even in the absence of gross metastases.
Subspecialties: Cardiothoracics
For years, the Cox-Maze Procedure IV (CMP-IV) has been the most efficacious atrial fibrillation (AF) and is the golden standard of treatment. Essentially it is the creation of scar tissue which will block the abnormal signals and rhythm that leads to atrial fibrillation. However, some studies have observed an increase in morbidity and mortality in patients undergoing CMP-IV with an enlarged atrium, especially when > 6.5cm (aka Giant Left Atrium; GLA). Due to this, many surgeons regard atrial dilation as a contraindication to the CMP-IV. But an increased “risk” does not always mean “contraindication.”
Patients underwent an elective CMP-IV with atrial diameter measurement to strictly define the use of CMP-IV in GLA patients. Patients were stratified by GLA (>6.5cm; n=72) and non-GLA (<6.5cm; n=714). Success was determined if any episode of AF, atrial flutter, or atrial tachycardia > 30 seconds was considered an atrial tachyarrhythmia (ATA) recurrence.
A trend toward increased 30-day mortality rates in the GLA group was observed, but without statistical significance (p=0.051). All these observations could be justified by the increase in comorbidities and complexity of GLA rather than the CMP-IV procedure itself. It was confirmed through the stricter success definition that for every 1 cm increase in atrial diameter the odds of ATA recurrence within 5 years increased by 37% (p<0.001), but by applying the clinically relevant model, there was no difference in rates of freedom. At 5 years the GLA group saw 82% of patients were free from ATA recurrence and 76% free from ATA/AADs. Though there was a decrease in overall survival in the GLA group (p=0.019), survival did not diverge until year 4 post operation. It is concluded that GLA should not preclude a patient from receiving CMP-IV. It is odd that the definition of GLA must be adjusted to provide successful results and then still have an increased overall mortality rate. It would be interesting to see other institutes complete this project using both definitions of GLA and provide a larger GLA sample size.
Subspecialties: Orthopedics
Postoperative knee stiffness can occur as a complication following total knee arthroplasty (TKA). The use of manipulation under anesthesia (MUA) for persistent early stiffness can be an effective method as long as it's utilized 6-12 weeks postoperatively. The use of COX-2 inhibitors are often required following TKA for their antiplatelet and anti-inflammation properties.In this retrospective study researchers aimed to see whether the risk of stiffness in patients undergoing TKA with DOAC anticoagulation was influenced by the use of a selective COX-2 inhibitor versus aspirin. Patients selected in the study were placed in one of three cohorts: (a) Aspirin + NSAID (n=1071), (b) DOAC Alone (n=92), or (c) DOAC + NSAID (n=195).
Results show no significant difference in MUA rates between patients receiving DOACs vs Aspirin (OR 1.768, 95% CI: 0.839 – 3.725, p = 0.134).However, there were significantly increased risk of MUA in the DOAC Alone cohort (OR 3.174, 95% CI: 1.123 – 9.974, p = 0.029). This increased risk was not present in the DOAC only cohort when compared to the Aspirin + DOAC cohort (OR 1.303, 95% CI: 0.518 – 3.277, p = 0.573). There were no significant outcomes in postoperative arc of motion in all groups at week 6. By 3 months, the Aspirin + NSAID cohort shown to improve outcomes in postoperative arc of motion compare to DOAC+ Aspirin cohort( 54.9% vs 42.7%, p=0.006) or DOAC alone cohort( 54.9% vs 38.5%, p=0.006). At 1 year follow-up, the Aspirin + DOAC cohort significantly improved than DOAC Alone (67.5% vs 51.1%, p=0.034). But there were no significant difference between the Aspirin + NSAID cohort and the DOAC + NSAID cohort (67.5% vs 61.5%, p= 0.252). Limitations of the study include: tourniquet usage, patient compliance, and preoperative tranexamic acid usage. And yet, the researchers showed that the use of DOAC alone worsen knee stiffness while aspirin + NSAID regimen improves postoperative stiffness.
Subspecialties: Neurosurgery
In the world of neurosurgery, cranioplasties are a routine operation. Although cranioplasties offer young residents with a robust learning opportunity, it is not without risk. In fact, the postoperative complications of cranioplasties are quite high. Given the concerning rate of infections (40%), the implantation success is only as good as the material used.
This prospective, randomized multicenter trial is the first of its kind to evaluate infection rate at 6 months after a cranioplasty with titanium vs hydroxyapatite (HA). 52 adult patients with a defect size greater than 16cm2 requiring a cranioplasty were randomized to receive either titanium or HA as the material for implantation. Postoperatively, local and systemic infection rates were monitored at discharge, 1 month, and 6 months. Overall, the titanium group (20.8%) had more infections as compared to the HA group (7.7%) (p<0.031). Additionally, both local and systemic rates of infection were higher in the titanium group, but it was not statistically significant. Interestingly, the HA group which had lower rates of infection actually had higher rates of postoperative hematomas (48%) compared to titanium (17%) (p<0.079).
Although cranioplasties remain necessary, they continue to have significant risk of postoperative complications. Luckily, this study shows that when it comes to lowering infection rates, the material of consideration should be HA. However, HA poses its own specific risk. Regarding limitations, sample size could be bigger. It’s interesting that there was no use of antibiotics preoperatively or postoperatively as part of the protocol. Would the rates of infection be lower if preoperatively all patients were given prophylaxis? A future study may find it worth investigating.
SURGEON SPOTLIGHT OF THE MONTH
This article mentions sensitive content regarding suicide, which some may find unsettling. If you or someone you know is suicidal, please get help from your local ER or call the suicide prevention hotline in your country.
Dr. René Gerónimo Favaloro
July 12 1923 - July 29 2000
In this issue, we will examine the touching and tragic life of Dr. René Gerónimo Favaloro, the legendary cardiothoracic surgeon best known for his contribution for pioneering the coronary artery bypass surgery using the great saphenous vein. A man of great compassion, he pursued medicine and practiced general medicine in rural Argentina out of selflessness for his community before joining the Cleveland Clinic to pursue cardiothoracic surgery to improve surgical outcomes of his home region in Buenos Aires.
Dr. Favaloro was born in La Plata, Argentina. He attended the School of Medicine at the National University of La Plata in 1941 and finished residency at the Hospital Policlínico San Martín in 1949. He later worked as a small-town doctor in Jacinto Aráuz in the rural La Pampa Province from 1950 until 1962. Jacinto Aráuz was not an affluent region of Argentina, and many of the villagers lived in poverty without access to basic hygiene, an observation that had a lasting impact on how Favaloro would approach medicine until the very last day of his life. After his brother graduated from medical school and joined him in La Pampa, Favaloro and his brother worked tirelessly to improve the quality of life of the impoverished community by establishing an operating room and the first blood donation facility in the province with their own savings and limited resources.
Despite his humble beginnings in rural medicine, Dr. Favaloro developed his interest in cardiothoracic surgery from regular contact with his mentors in La Plata, Dr. Federico Christmann and Dr. José Mar'a Mainetti. Federico and Mainetti would later recommend the Cleveland Clinic as a possible route to train in the latest advancements in the field. Favaloro’s interest and dedication led him to a visit to Dr. Crile and Dr. Effler in Cleveland. Effler, the head of cardiac surgery at the time, would later accept him as a resident in 1963.
While at the Cleveland Clinic, Favaloro was mentored by Dr. Mason Sones and Dr. William Proudfit, who were both heavily involved in the radical search for a surgical solution for bypassing coronary obstructions. At the time, direct myocardial revascularization for localized proximal coronary obstructions was carried out by the pericardial or venous patch-graft technique. A major disadvantage of this technique was that the arteriosclerotic plaque was allowed to remain in place, which often progressed or resulted in a secondary thromboembolic occlusion. The technique produced satisfactory results on cases involving the right coronary artery, but not cases involving the left main trunk. By 1968, Favaloro and his team would later mitigate the daunting left main artery disease by implementing a single bypass to the proximal segment of the left anterior descending branch, which showed excellent postoperative perfusion.
Favaloro made the difficult decision to return to Argentina to fulfill his promise of bringing advanced surgical expertise back to his community in 1970. His departure was protested by his mentors and the staff at the Cleveland Clinic as the institution had considered him an indispensable part of the cardiac surgery department. Nonetheless, Favaloro was warmly welcomed back into Argentina, where he initially worked as the Chief of Cardiac Surgery at Clinica Güemes before establishing the Favaloro Foundation in 1975. The Favaloro Foundation was developed as Dr. Favaloro’s vision to bring the same spirit of excellence in medical care and research as the Cleveland Clinic. By 1999, more than 400 cardiologists and cardiovascular surgeons were trained at the Foundation and actively providing care all over Latin America.
In the earlier days of the Foundation, the economic climate of Argentina was favorable, so there was little to no concern on maintaining the immense budget required to keep the Foundation afloat. By the late 1990s, Argentina’s economic climate was no longer in good standing. Favaloro suffered loss after loss due to defaults in payments from other hospitals and the government, estimating around $18 million. At the end of his life at the age of 77, Favaloro had poured his soul into developing the Foundation, which he understandably was desperate to save amidst the financial obstacles. As a last plea for the support of his Foundation and the lifesaving advances it generously provided, Favaloro wrote a letter to the President of Argentina pleading for the debt that the government had owed his institution. A week later, on July 29, 2000, Dr. René Favaloro was found dead in his apartment by a self-inflicted gunshot wound to the chest.
The international medical community mourned for his death, a shock across both Latin America and the United States. The world in that moment mourned the loss of an exceptional man, not just a physician or surgeon. In the numerous memoirs of him, Dr. Favaloro was regarded as a compassionate and humble man who genuinely touched the hearts of everyone he encountered even outside of medicine and surgery. He was remembered fondly by his patients and community as a fearless champion against injustice and oppression. To his colleagues, they recall his somber grief after the death of his patients, how he spent hours scrutinizing and recalling details of his decisions that were suspected to contribute to their unfortunate outcome. He was a dreamer who was generous and kind, someone who loved the ones he took care of enough to break his own heart in order to fix theirs.
Today, the Favaloro Foundation lives on. After his death, a new board of directors saved the Foundation by restructuring the overall management and placing more emphasis on fundraising. The Favaloro Foundation today provides highly specialized services in cardiology, cardiovascular surgery, pulmonology, nephrology, hepatology, and immunogenetics with an emphasis on serving the indigenous and impoverished populations of Argentina, just as how Dr. Favaloro would have envisioned.
Sources:
https://www.fundacionfavaloro.org/welcome-to-the-favaloro-foundation/
Favaloro RG. Surgical treatment of acute myocardial infarction. Journal of the American College of Cardiology. 2000 Apr 1;35(5):18B-24B.
Krauss, Clifford (August 7, 2000). "Argentina Searches Its Soul Over a Suicide". The New York Times. Retrieved 15 June 2009.
Captur G. Memento for René Favaloro. Tex Heart Inst J. 2004;31(1):47-60. PMID: 15061628; PMCID: PMC387434. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC387434/
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