Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Comparison of Tramadol Versus Bupivacaine as Local Anesthetic in Pain Control in Inguinal Hernia Surgery

OBJECTIVE: To compare the outcomes of local infiltration of tramadol versus bupivacaine for post operative pain control and time to mobilize patients out of bed with less intravenous analgesia consumption in  Inguinal hernia surgery. Methodology: This randomized controlled trail study was  conducted at the department of General Surgery,  Pakistan Institute of Medical Sciences (PIMS) Islamabad over a period of one year. It includes 122 patients which were randomly allocated to either Group A/T (Tramadol, n=61 ) or Group B(Bupivacaine, n=61). Group T  was study group while Group B was control group. The  patients were operated on elective operative list. The relevant data was collected in ward on a well structured proforma showing post operative pain score according to visual analogue scale(VAS) at 3, 6, 12, 24 hrs, time of first analgesia and time to mobilize out of bed in hours.There were no confounding variables in this study. Results: Overall the mean age of patients was 33± 8 yrs. In Bupivacaine group the mean age was 34 ± 9 years and in Tramadol group was 31 ± 8 years. At 24th hour after surgery the mean pain score in Bupivacaine group was 5.2± 1 and in Tramadol group was 2.7± 0.5. The mean Pain in Tramadol group was statistically less when compared to Bupivacaine group at 3rd, 6th, 12th and 24th hours, p-value < 0.001. The mean time of first analgesia on demand in Bupivacaine group was 10 ± 7 hours and in Tramadol group was 13.5 ± 5.6 hours, the average duration for 1st analgesia requirement was statistically greater in Tramadol group, p-value < 0.05. The mean period of mobilization out of bed in Bupivacaine group was 9 ± 4 hours and in Tramadol group was 6 ± 4.5 hours. The mean time to mobilize out of bed (hours) was statistically lower in Tramadol group in comparison with Bupivacaine group, p-value < 0.001. Conclusion:  Current study  concluded that local infiltration with tramadol was effective in reducing pain, delaying analgesia on  demand and for less time to mobile patient out of bed when compared with Bupivacaine group.Therefore cases undergoing Inguinal hernia repair may be offered Tramadol infiltration at the time of wound closure to have better outcomes and to gain patient satisfaction

Postoperative Outcomes of Low Pressure versus Standard Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy

Objective: To compare outcomes in laparoscopic cholecystectomy performed with either low-pressure pneumoperitoneum (LPP <12 mm Hg) or standard-pressure pneumoperitoneum (SPP >12 mm Hg). Methodology: This randomized trial was conducted over six months, from September 2020 to March 2021, with data prospectively collected from patients. Patients aged 20-60 years with symptomatic gallstones were divided between Group A or Group B randomly, with 31 patients in each group. Group A underwent surgery with low-pressure pneumoperitoneum (LPP), whereas Group B underwent surgery with standard-pressure pneumoperitoneum (SPP). Postoperative ileus was assessed at six hours, while shoulder tip pain was evaluated at 24 hours post-surgery, and comparisons were made between both groups. Results: There were 16 males and 15 females in group A and 14 males and 17 females in group B. Mean age in Group A was 40.35±7.27 years and in Group B 42.28±6.95 years. Group A had an average hospital stay of 1.06 ± 0.21 days and Group B had 1.09 ± 0.37 days. 10 patients (32.3%) experienced right shoulder tip pain in the LPP group as compared to 19 patients (61.3%) in the SPP group (p=0.021). Paralytic ileus was noticed in 6 patients (19.4%) in Group A and 16 patients (51.6%) in Group B (p<0.007). Conclusion: LLP is a possible and safe option that significantly reduces postoperative shoulder tip pain and paralytic ileus, facilitating earlier bowel recovery compared to standard-pressure pneumoperitoneum

Patient Selection in One Anastomosis/Mini Gastric Bypass-an Expert Modified Delphi Consensus

Purpose: One anastomosis/mini gastric bypass (OAGB/MGB) is up to date the third most performed obesity and metabolic procedure worldwide, which recently has been endorsed by ASMBS. The main criticisms are the risk of bile reflux, esophageal cancer, and malnutrition. Although IFSO has recognized this procedure, guidance is needed regarding selection criteria. To give clinicians a daily support in performing the right patient selection in OAGB/MGB, the aim of this paper is to generate clinical guidelines based on an expert modified Delphi consensus. Methods: A committee of 57 recognized bariatric surgeons from 24 countries created 69 statements. Modified Delphi consensus voting was performed in two rounds. An agreement/disagreement among ≥ 70.0% of the experts was considered to indicate a consensus. Results: Consensus was achieved for 56 statements. Remarkably, ≥ 90.0% of the experts felt that OAGB/MGB is an acceptable and suitable option "in patients with Body mass index (BMI) > 70, BMI > 60, BMI > 50 kg/m2 as a one-stage procedure," "as the second stage of a two-stage bariatric surgery after Sleeve Gastrectomy for BMI > 50 kg/m2 (instead of BPD/DS)," and "in patients with weight regain after restrictive procedures. No consensus was reached on the statement that OAGB/MGB is a suitable option in case of resistant Helicobacter pylori. This is likely as there is a concern that this procedure is associated with reflux and its related long-term complications including risk of cancer in the esophagus or stomach. Also no consensus reached on OAGB/MGB as conversional surgery in patients with GERD after restrictive procedures. Consensus for disagreement was predominantly achieved "in case of intestinal metaplasia of the stomach" (74.55%), "in patients with severe Gastro Esophageal Reflux Disease (GERD)(C,D)" (75.44%), "in patients with Barrett's metaplasia" (89.29%), and "in documented insulinoma" (89.47%). Conclusion: Patient selection in OAGB/MGB is still a point of discussion among experts. There was consensus that OAGB/MGB is a suitable option in elderly patients, patients with low BMI (30-35 kg/m2) with associated metabolic problems, and patients with BMIs more than 50 kg/m2 as one-stage procedure. OAGB/MGB can also be a safe procedure in vegetarian and vegan patients. Although OAGB/MGB can be a suitable procedure in patients with large hiatal hernia with concurrent hiatal hernia, it should not be offered to patients with grade C or D esophagitis or Barrett's metaplasia

Global 30-Day Morbidity and Mortality of Primary Bariatric Surgery Combined with Another Procedure: The BLEND Study

BackgroundNo robust data are available on the safety of primary bariatric and metabolic surgery (BMS) alone compared to primary BMS combined with other procedures.ObjectivesThe objective of this study is to collect a 30-day mortality and morbidity of primary BMS combined with cholecystectomy, ventral hernia repair, or hiatal hernia repair.SettingThis is as an international, multicenter, prospective, and observational audit of patients undergoing primary BMS combined with one or more additional procedures.MethodsThe audit took place from January 1 to June 30, 2022. A descriptive analysis was conducted. A propensity score matching analysis compared the BLEND study patients with those from the GENEVA cohort to obtain objective evaluation between combined procedures and primary BMS alone.ResultsA total of 75 centers submitted data on 1036 patients. Sleeve gastrectomy was the most commonly primary BMS (N = 653, 63%), and hiatal hernia repair was the most commonly concomitant procedure (N = 447, 43.1%). RYGB accounted for the highest percentage (20.6%) of a 30-day morbidity, followed by SG (10.5%). More than one combined procedures had the highest morbidities among all combinations (17.1%). Out of overall 134 complications, 129 (96.2%) were Clavien-Dindo I-III, and 4 were CD V. Patients who underwent a primary bariatric surgery combined with another procedure had a pronounced increase in a 30-day complication rate compared with patients who underwent only BMS (12.7% vs. 7.1%).ConclusionCombining BMS with another procedure increases the risk of complications, but most are minor and require no further treatment. Combined procedures with primary BMS is a viable option to consider in selected patients following multi-disciplinary discussion

30-Day morbidity and mortality of bariatric metabolic surgery in adolescence during the COVID-19 pandemic – The GENEVA study

Background: Metabolic and bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. Objectives: This study examined the safety of MBS in adolescents during the coronavirus disease 2019 (COVID-19) pandemic. Methods: This was a global, multicentre and observational cohort study of MBS performed between May 01, 2020, and October 10,2020, in 68 centres from 24 countries. Data collection included in-hospital and 30-day COVID-19 and surgery-specific morbidity/mortality. Results: One hundred and seventy adolescent patients (mean age: 17.75 ± 1.30 years), mostly females (n = 122, 71.8%), underwent MBS during the study period. The mean pre-operative weight and body mass index were 122.16 ± 15.92 kg and 43.7 ± 7.11 kg/m2, respectively. Although majority of patients had pre-operative testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (n = 146; 85.9%), only 42.4% (n = 72) of the patients were asked to self-isolate pre-operatively. Two patients developed symptomatic SARS-CoV-2 infection post-operatively (1.2%). The overall complication rate was 5.3% (n = 9). There was no mortality in this cohort. Conclusions: MBS in adolescents with obesity is safe during the COVID-19 pandemic when performed within the context of local precautionary procedures (such as pre-operative testing). The 30-day morbidity rates were similar to those reported pre-pandemic. These data will help facilitate the safe re-introduction of MBS services for this group of patients