Age has historically been used to predict negative post-surgical outcomes. The concept of frailty was introduced to explain the discrepancies that exist between patients’ chronological and ...physiological age. The efficacy of the modified frailty index (mFI) to predict surgical risk is not clear.
We sought to synthesize the current literature to quantify the impact of frailty as a prognostic indicator across all surgical specialties.
Pubmed and Cochrane databases were screened from inception to 1 January 2018.
Studies utilizing the modified Frailty Index (mFI) as a post-operative indicator of any type of surgery. The mFI was selected based on a preliminary search showing it to be the most commonly applied index in surgical cohorts.
Articles were selected via a two-stage process undertaken by two reviewers (AP and DS). Statistical analysis was performed in Revman (Review manager V5.3). The random-effects model was used to calculate the Risk Ratios (RR).
The primary outcomes: post-operative complications, re-admission, re-operation, discharge to a skilled care facility, and mortality.
This meta-analysis of 16 studies randomizes 683,487 patients, 444,885 frail, from gastrointestinal, vascular, orthopedic, urogenital, head and neck, emergency, neurological, oncological, cardiothoracic, as well as general surgery cohorts. Frail patients were more likely to experience complications (RR 1.48, 95%CI 1.35–1.61; p < 0.001), major complications (RR 2.03, 95%CI 1.26–3.29; p = 0.004), and wound complications (RR 1.52, 95%CI 1.47–1.57; p < 0.001). Furthermore, frail patients had higher risk of readmission (RR 1.61, 95%CI 1.44–1.80; p < 0.001) and discharge to skilled care (RR 2.15, 95%CI 1.92–2.40; p < 0.001). Notably, the risk of mortality was 4.19 times more likely in frail patients (95% CI 2.96–5.92; p < 0.001).
and Relevance: This study is the first to synthesize the evidence across multiple surgical specialties and demonstrates that the mFI is an underappreciated prognostic indicator that strongly correlates with the risk of post-surgical morbidity and mortality. This supports that formal incorporation of pre-operative frailty assessment improves surgical decision-making.
•The mFI correlates with higher rates of post-operative complications, readmission, reoperation, and mortality.•Formal incorporation of preoperative frailty assessment using the mFI can improve surgical risk stratification.
In reconstructive surgery, tissues are routinely transferred to repair a defect caused by trauma, cancer, chronic diseases, or congenital malformations; surgical transfer intrinsically impairs ...metabolic supply to tissues placing a risk of ischemia-related complications such as necrosis, impaired healing, or infection. Pre-surgical induction of angiogenesis in tissues (preconditioning) can limit postsurgical ischemic complications and improve outcomes, but very few preconditioning strategies have successfully been translated to clinical practice due to the invasiveness of most proposed approaches, their suboptimal effects, and their challenging regulatory approval. We optimized a method that adopts noninvasive external suction to precondition tissues through the induction of hypoxia-mediated angiogenesis. Using a sequential approach in a rodent model, we determined the parameters of application (frequency, suction levels, duration, and interfaces) that fine-tune the balance of enhanced angiogenesis, attenuation of hypoxic tissue damage, and length of treatment. The optimized repeated short-intermittent applications of intermediate suction induced a 1.7-fold increase in tissue vascular density after only 5 days of treatment (
p
< 0.05); foam interfaces showed the same effectiveness and caused less complications. In a second separate experiment, our model showed that the optimized technique significantly improves survival of transferred tissues. Here we demonstrate that noninvasive external suction can successfully, safely, and promptly enhance vascularity of soft tissues: these translational principles can help design effective preconditioning strategies, transform best clinical practice in surgery, and improve patient outcomes.
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When adipose tissue (AT) is impaired by trauma or disease, AT engineering could provide a shelf-ready structural and functional restoration as alternative to current clinical ...treatments, which mainly aim at aesthetic replacement. Yet, the lack of an efficient vascular network within the scaffolds represents a major limitation to their translation application in patients. Here, we propose the use of microstructured crosslinked gelatin hydrogels with an embedded prevascular channel as scaffolding materials for AT engineering. The scaffolds are fabricated using – simultaneously – alginate-based microbeads and 3D printed filaments as sacrificial material encapsulated in gelatin at the point of material fabrication and removed post-crosslinking. This method yields the formation of microstructures that resemble the micro-architecture of physiological human fat tissue and of microvessels that can facilitate vascularization through anastomosis with patients’ own blood vessels. The cytocompatible method used to prepare the gelatin scaffolds showed structural stability over time while allowing for cell infiltration and protease-based remodeling/degradation. Scaffolds’ mechanical properties were also designed to mimic the one of natural breast adipose tissue, a key parameter for AT regeneration. Scaffold’s embedded channel (∅ = 300–400 µm) allowed for cell infiltration and enabled blood flow in vitro when an anastomosis with a rat blood artery was performed using surgical glue. In vitro tests with human mesenchymal stem cells (hMSC) showed colonization of the porous structure of the gelatin hydrogels, differentiation into adipocytes and accumulation of lipid droplets, as shown by Oil Red O staining.
The potential clinical use of scaffolds for adipose tissue (AT) regeneration is currently limited by an unmet simultaneous achievement of adequate structural/morphological properties together with a promoted scaffold vascularization. Sacrificial materials, currently used either to obtain a tissue-mimicking structure or hollow channels to promote scaffold’ vascularization, are powerful versatile tools for the fabrication of scaffolds with desired features. However, an integrated approach by means of sacrificial templates aiming at simultaneously achieving an adequate AT-mimicking structure and hollow channels for vascularization is missing. Here, we prove the suitability of crosslinked gelatin scaffolds obtained by using sacrificial alginate microbeads and 3D printed strands to achieve proper features and hollow channels useful for scaffolds vascularization.
The efficacy of NPWT in promoting wound healing has been largely accepted by clinicians, yet the number of high-level clinical studies demonstrating its effectiveness is small and much more can be ...learned about the mechanisms of action. In the future, hopefully we will have the data to assist clinicians in selecting optimal parameters for specific wounds including interface material, waveform of suction application, and the amount of suction to be applied. Further investigation into specific interface coatings and instillation therapy are also needed. We believe that advances in mechanobiology, the science of wound healing, the understanding of biofilms, and advances in cell therapy will lead to better care for our patients.
The SCARE guideline was developed in 2016 through an expert Delphi consensus exercise. It aimed to improve the quality of reporting of surgical case reports. The aim of this study was to assess the ...impact of introducing the SCARE guideline for surgical on reporting of case reports submitted to a single journal.
A total of 20 case reports published in the International Journal of Surgery Case Reports (IJSCR) and Annals of Medicine and Surgery (AMS) in July and August 2016, prior to the introduction of the SCARE guideline (the pre-SCARE period), were randomly identified and scored against the SCARE criteria. Two independent teams performed the scoring giving a total score out of a theoretical maximum of 34 for each case report, the ‘SCARE score’ (expressed as a percentage). The scores for the two teams were then compared and consensus was reached to achieve a final sore set. This process was repeated for the January and February 2017 issues of the journal, post implementation of the guideline (the post-SCARE period). SCARE scores were compared between the pre- and post-SCARE periods.
The mean pre-SCARE score was 75.0% (standard deviation ± 6.29, Range 62–84), and the mean post-SCARE score was 82.6% (standard deviation ± 8.02, range 66–99), a 10% relative increase in compliance which was statistically significant (P < 0.001). The Cohen's Kappa score between teams A and B was 0.871, implying very substantial agreement.
Implementation of the SCARE guideline resulted in a 10% improvement in the reporting quality of surgical case reports published in a single journal. Adherence to SCARE reporting guidelines by authors, reviewers and editors should be improved to boost reporting quality. Journals should develop their policies, submission processes and guide for authors to incorporate the guideline.
•Adherence to the SCARE reporting guideline by authors, reviewers and editors should be improved to boost reporting quality.•Journals publishing surgical case reports should consider incorporating the SCARE guideline within their submission process.•Journals utilising the SCARE guideline may see a benefit in reporting quality.•We have determined the criteria that are most frequently missed, providing a focus area for efforts going forward.
Background
The use of nipple‐sparing mastectomy (NSM) is increasing, despite unproven oncological safety in the therapeutic setting. The aim of this systematic review was to determine the safety and ...efficacy of NSM compared with skin‐sparing mastectomy (SSM).
Methods
A literature search of all original studies including RCTs, cohort studies and case–control studies comparing women undergoing therapeutic NSM or SSM for breast cancer was undertaken. Primary outcomes were oncological outcomes; secondary outcomes were clinical, aesthetic, patient‐reported and quality‐of‐life outcomes. Data analysis was undertaken to explore the relationship between NSM and SSM, and preselected outcomes. Heterogeneity was assessed using the Cochrane tests.
Results
A total of 690 articles were identified, of which 14 were included. There was no statistically significant difference in 5‐year disease‐free survival and mortality for NSM and SSM groups, where data were available. Local recurrence rates were also similar for NSM and SSM (3·9 versus 3·3 per cent respectively; P = 0·45). NSM had a partial or complete nipple necrosis rate of 15·0 per cent, and a higher complication rate than SSM (22·6 versus 14·0 per cent respectively). The higher overall complication rate was due to the rate of nipple necrosis in the NSM group (15·0 per cent).
Conclusion
In carefully selected cases, NSM is a viable choice for women with breast cancer who need to have a mastectomy. More research is needed to help further refine which surgical approaches to NSM optimize outcomes.
The objective of this systematic review was to determine the safety and efficacy of nipple‐sparing mastectomy (NSM) as compared with skin‐sparing mastectomy (SSM). In carefully selected cases, NSM is a viable choice for women with breast cancer needing to undergo mastectomy. More research is needed to help further refine the evidence on which surgical approaches to NSM optimize outcomes.
Nipple‐sparing can be a safe choice
Background
Case series are an important and common study type. No guideline exists for reporting case series and there is evidence of key data being missed from such reports. The first step in the ...process of developing a methodologically sound reporting guideline is a systematic review of literature relevant to the reporting deficiencies of case series.
Methods
A systematic review of methodological and reporting quality in surgical case series was performed. The electronic search strategy was developed by an information specialist and included MEDLINE, Embase, Cochrane Methods Register, Science Citation Index and Conference Proceedings Citation index, from the start of indexing to 5 November 2014. Independent screening, eligibility assessments and data extraction were performed. Included articles were then analysed for five areas of deficiency: failure to use standardized definitions, missing or selective data (including the omission of whole cases or important variables), transparency or incomplete reporting, whether alternative study designs were considered, and other issues.
Results
Database searching identified 2205 records. Through the process of screening and eligibility assessments, 92 articles met inclusion criteria. Frequencies of methodological and reporting issues identified were: failure to use standardized definitions (57 per cent), missing or selective data (66 per cent), transparency or incomplete reporting (70 per cent), whether alternative study designs were considered (11 per cent) and other issues (52 per cent).
Conclusion
The methodological and reporting quality of surgical case series needs improvement. The data indicate that evidence‐based guidelines for the conduct and reporting of case series may be useful.
Guidelines are needed
Background
Calls for greater transparency with improved quality, safety and outcomes have led to performance tracking of individual surgeons. This study evaluated the methodology of studies ...investigating individual performance in surgery.
Methods
MEDLINE, Embase, PsycINFO, AMED and the Cochrane Database of Systematic Reviews (from their inception to July 2014) were searched. Two authors independently reviewed citations using predetermined inclusion and exclusion criteria; 91 data points per study were extracted.
Results
The search strategy yielded 8514 citations; 101 were eligible, comprising 1 006 037 procedures by 14 455 surgeons. Thirty‐four studies were prospective and 66 were retrospective. The aim of the studies was either to assess individual performance and describe the learning curve of a procedure, to describe factors influencing performance, or to describe methods for routine performance monitoring. Some 51·5 per cent of the studies investigated 500 or fewer procedures. Most (77 of 101) were single‐centre studies. Less than half of the studies (42, 41·6 per cent) employed statistical modelling or stratification to adjust performance measures. Forty studies (39·6 per cent) adjusted outcomes for case mix. Seventeen (16·8 per cent) adjusted metrics for surgeon‐specific factors. Thirteen studies (12·9 per cent) considered clustering in their analyses. The most frequent outcome studied was duration of operation (59·4 per cent), followed by complication rate (45·5 per cent) and reoperation rate (29·7 per cent); 15·8 per cent of studies recorded mortality, and 4·0 per cent explored patient satisfaction. Only 48·5 per cent of studies displayed procedural learning curves using a graph.
Conclusion
There exist substantial shortcomings in methodological quality, outcome measurements and quality improvement evaluation among current studies of individual surgical performance. Methodological guidelines should be established to ensure that assessments are valid.
Many shortcomings
When tissue is subjected to higher than physiological temperatures, protein and cell organelle structures can be altered resulting in cell death and subsequent tissue necrosis. A burn injury can be ...stratified into three main zones, coagulation, stasis and edema, which correlate with the extent of heat exposure and thermal properties of the tissue. While there has been considerable effort to characterize the time–temperature dependence of the injury, relatively little attention has been paid to the other important variable, the thermal susceptibility of the tissue. In the present study, we employ a standard physical chemistry approach to predict the level of denaturation at supraphysiological temperatures of 12 vital proteins as well as RNA, DNA and cell membrane components. Melting temperatures and unfolding enthalpies of the cellular components are used as input experimental parameters. This approach allows us to establish a relation between the level of denaturation of critical cellular components and clinical manifestations of the burn through the characteristic zones of the injury. Specifically, we evaluate the degree of molecular alteration for characteristic temperature profiles at two different depths (Mid-Dermis and Dermis-Fat interface) of 80
°C; 20
s contact burn. The results of this investigation suggest that the thermal alteration of the plasma membrane is likely the most significant cause of the tissue necrosis. The lipid bilayer and membrane-bound ATPases show a high probability of thermal damage (almost 100% for the former and 85% for the latter) for short heat exposure times. These results suggest that strategies to minimize the damage in a burn injury might focus on the stabilization of the cellular membrane and membrane-bound ATPases. Further work will be required to validate these predictions in an in vivo model.
The PROCESS guideline was developed in 2016 through expert Delphi consensus. It aimed to improve the quality of reporting of surgical case series. This study assessed the impact of the introduction ...of the PROCESS guideline on reporting for surgical case series submitted to three journals.
20 case series published in the International Journal of Surgery Case Reports (IJSCR), the International Journal of Surgery (IJS) or the Annals of Medicine and Surgery (AMS) in September to December 2016, prior to the introduction of the PROCESS guideline (the pre-PROCESS period), were randomly identified and scored against the PROCESS criteria. Two authors independently scored each article a total score out of 29, the 'PROCESS score' (expressed as a percentage). Scores for the two researchers were compared and consensus was reached to achieve a final score set. The process was repeated for the January 2017 to April 2017 issues of the three journals, post PROCESS implementation (the post-PROCESS period).
The mean PROCESS score was 80% (range 66–90%) for the pre-PROCESS period and 84% (range 72–95%) for the post-PROCESS period, a 4% relative increase STATS. The Cohen's Kappa score between researchers was 0.907 implying very substantial agreement.
Implementation of the PROCESS guideline resulted in a 5% improvement in the reporting quality of surgical case series published in three journals. Further research is needed to identify and successfully navigate existing barriers to greater compliance. Authors, reviewers and editors should adhere to the guidelines to boost reporting quality. Journals should develop their policies and guide for authors to incorporate the guideline and mandate compliance.
•This is the first assessment of the PROCESS guidelines since its publication.•There was a 5% increase in concordance with the PROCESS guidelines after publication.•Research is needed to identify and navigate existing barriers to greater compliance.•Authors, reviewers and editors should adhere to the guidelines to boost reporting quality.
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