2 Minute Medicine Rewind March 6, 2023

Performance of General Surgical Procedures in Outpatient Settings Before and After Onset of the COVID-19 Pandemic

1. Rates of outpatient surgery for several general surgery procedures were increased during the onset of the COVID-19 pandemic.

Evidence Rating Level: 2 (Good)

During the COVID-19 pandemic, guidelines from the American College of Surgeons (ACS) recommended increasing surgical load performed in an outpatient setting, to minimize risk of nosocomial infection for surgical patients, and to increase the number of beds available for COVID-19 patients. Several procedures have previously been shown to be feasible and safe in outpatient settings, with same-day discharge associated with reductions in infection rates and cost, as well as improved patient satisfaction. This retrospective study aimed to trend the rates of outpatient general surgery procedures from 2016 to 2020, to encompass the start of the pandemic. This study included hospitals in the USA partaking in the ACS National Surgical Quality Improvement Program, and trended the 16 common general surgery procedures, including breast surgery, endocrine surgeries, and minimally invasive (MIS) hernia repairs, gastric surgery, cholecystectomy, and colectomy for cancer. The evaluated outcome was the odds of outpatient surgery for each year of the study. In total, there were 988,436 patients studied, with 823,746 before the pandemic and 164,690 after. The study found that from 2016-2020, 4 procedures had clinically significant (≥10%) increases, including mastectomy for breast cancer (9.2% to 28.6%), thyroid lobectomy (43.2% to 57.9%), MIS ventral hernia repair (58.8% to 69.4%), and parathyroidectomy (51.8% to 61.8%). These trends were also assessed between 2019-2020 to capture data before and after the start of the pandemic, with 8 procedures having significant differences (p < 0.001) in outpatient surgery rates, including: Mastectomy (odds ratio 2.44, 95% CI 2.28-2.61), MIS adrenalectomy (OR 1.96, 95% CI 1.37-2.81), thyroid lobectomy (OR 1.43, 95% CI 1.32-1.55), breast lumpectomy (OR 1.35, 95% CI 1.24-1.47), MIS ventral hernia repair (OR 1.21, 95% CI 1.15-1.27), MIS sleeve gastrectomy (OR 2.52, 95% CI 1.86-3.40), parathyroidectomy (OR 1.22, 95% CI 1.13-1.32), and total thyroidectomy (OR 1.51, 95% CI 1.40-1.62). Overall, this study demonstrated that the COVID-19 pandemic was associated with higher rates of outpatient surgery for some general surgery procedures, leading to potential future studies assessing the implications of this increased outpatient surgery load.

Effect of an Exclusive Human Milk Diet on the Gut Microbiome in Preterm Infants: A Randomized Clinical Trial

1. There were no significant differences in morbidity or gut microbiota diversity, for preterm infants randomized to supplementing a mother’s own breast milk (MOM) with bovine formula versus donor human milk.

Evidence Rating Level: 1 (Excellent)

In preterm infants, consuming a mother’s own breast milk (MOM) has been associated with reductions in neonatal morbidity. However, when there is an insufficient amount of MOM supply, it is not entirely clear whether pasteurized donor human milk (DHM) versus bovine formula is the better choice. A meta-analysis did show lower rates of necrotizing enterocolitis (NEC) for DHM compared to formula, when these were the sole dietary options, but no difference when these were used to supplement low MOM supply. It is hypothesized that any potential differences in rates of NEC may be due to differences in gut microbiota from consuming DHM versus formula. Therefore, this randomized controlled trial aimed to assess differences in neonatal morbidity and gut microbiome diversity of preterm infants on a solely human milk diet compared to a diet with bovine formula. The study population consisted of infants born under 30 weeks of gestation, who did not receive milk apart from MOM in the first 3 days of life, and who did not have life-threatening comorbidities. The control consisted of infants feeding with MOM, and supplementing with formula, whereas the intervention consisted of infants feeding with MOM and supplementing with ready-to-feed pasteurized human milk. At 34 weeks, stool samples were collected and DNA sequenced to assess the gut microbiota. In total, there were 126 infants with 63 randomized to either group. The median (range) percentage of enteral intake from supplemental formula or ready-to-feed was 1% (0-100%) and 24% (0-99%) respectively. There were no significant differences in neonatal outcomes, such as time to full feeds, rates of NEC, weight gain, or length of stay. There were also no significant differences in bacterial richness or Shannon diversity, though there was decreased abundance of Lactobillus in the exclusive human milk group (p = 0.03). Overall, this study demonstrated no significant differences in neonatal morbidity outcomes or gut microbiome diversity when supplementing MOM with bovine formula compared to human milk.

Influence of poor sleep on cardiovascular disease-free life expectancy: a multi-resource-based population cohort study

1. Self-reported and clinically diagnosed poor sleep are associated with lower cardiovascular disease-free life expectancy, compared to patients with healthy sleep.

Evidence Rating Level: 2 (Good)

Poor sleep has been associated with greater risk of cardiovascular disease (CVD). A previous study found a 39% greater risk of CVD mortality in poor sleepers compared to healthy sleepers. However, there is a paucity of evidence pertaining to the association between sleep and CVD-free life expectancy at age 40. Therefore, this cohort study estimated the CVD-free years of life lost for patients with self-reported and clinically diagnosed poor sleep. The study population was taken from the UK Biobank. Each participant completed a baseline sleep questionnaire, with a 5-point score assigned based on insomnia, sleep duration (adequate being 7-9 hours), chronotype in the morning, daytime drowsiness, and snoring. The tallied scores were categorized into healthy sleep (4-5 points), intermediate sleep (2-3 points), and poor sleep (0-1 points). Additionally, health records were used to identify primary care encounters, hospital admissions, and prescriptions related to sleep disorders, such as insomnia, hypersomnia, circadian rhythm disorders, parasomnias, and sleep-related breathing disorders. CVD events were measured using CVD-related hospital admissions, with separate analyses conducted for men and women due to their differences in CVD risk. In total, there were 308,683 patients in the self-reported sleep analysis, and 140,181 in the clinically diagnosed sleep disorder analysis. The study found a lower CVD-free life expectancy at age 40 in patients with self-reported poor sleep compared to healthy sleep, with a difference of 1.80 (95% CI 0.96-2.75) years in women and 2.31 (95% CI 1.46-3.29) years in men. The hazards ratios for CVD in poor versus healthy sleepers were 1.13 (95% CI 1.05-1.22) in women and 1.17 (95% CI 1.09-1.26) in men. Additionally, there was a difference of 1.16 (95% CI 0.43-2.21) CVD-free years lost between those with clinically diagnosed sleep disorders, compared to those without. Overall, this study demonstrated that self-reported and clinically diagnosed poor sleep are associated with lower CVD-free life expectancy.

Liver function indicators in patients with breast cancer before and after detection of hepatic metastases-a retrospective study

1. For patients diagnosed with breast cancer liver metastases (BCLM), liver function tests were found to be elevated at 6 months prior to detection of metastases.

Evidence Rating Level: 2 (Good)

Breast malignancy is one of the leading causes of cancer-related mortality in women, and 20-30% of patients develop metastases. The liver is a common site of metastasis, and carries one of the lowest 5-year survival rates of 8.5%. Early surgical treatment of breast cancer liver metastases (BCLM) has been shown to improve life expectancy, underlining the importance of early detection. Previous studies have shown elevated liver enzymes at the time of diagnosing BCLM. This current study aimed to identify if markers of liver dysfunction are present before patients were subsequently diagnosed with BCLM. The study population consisted of 104 BCLM patients at a single centre in Vienna, from 1980 to 2019: 66.3% had liver markers measured 6 months before diagnosis, 71.2% at the time of diagnosis and 12 months after diagnosis, and 38.5% with measurements at all time points. The results showed that all of AST, ALT, GGT, LDH, and AP were elevated in 27.9%, 27.5%, 42.0%, 27.6%, and 39.7% of BCLM patients respectively 6 months before diagnosis, which were greater than the null hypothesis of 5% (p < 0.001). The number of liver mets also had a positive correlation with the levels of the above biomarkers at the time of diagnosis. 16.7% of patients had lower albumin, and there was a significantly lower albumin at time of diagnosis for patients who survived less than 12 months, compared to more than 12 months (p = 0.002). Additionally, 7.4% of BCLM patients had elevated bilirubin 6 months before diagnosis, which was not significant (p < 0.373). Overall, this study demonstrated that liver function tests in breast cancer patients could be used as a screen for BCLM, which could lead to earlier detection and treatment.

The safety and prognosis of radical surgery in colorectal cancer patients over 80 years old

1. In a Chinese cohort of colorectal cancer (CRC) patients over 80 years old, radical resection was found to be safe and feasible.

2. BMI and N stage are independent prognostic factors for cancer-specific survival (CSS) post radical resection.

Evidence Rating Level: 2 (Good)

The number of elderly patients receiving surgery for colorectal cancer (CRC) are increasing, due to overall increased life expectancy from improved living standards. However, medical comorbidities in the elderly population may affect surgical complication rates. Since guidelines do not recommend adjuvant chemotherapy and radiotherapy for CRC patients over 80 years, this study investigated the safety and feasibility of radical CRC surgery for patients over 80, as well as their prognosis without adjuvant treatment. The study population consisted of CRC patients from 3 medical centres in China, with pathologic confirmation of CRC and no metastasis. Surgery was done open or laparoscopic. The outcome measured was the 3-year cancer-specific survival (CSS) rate, defined as the time period between the surgery and death from cancer. In total, there were 372 patients included in the study. The mean (SD) operation time was 152.3 (58.1) minutes, the intraoperative blood loss was 67.6 (35.4) mL, the postoperative hospital stay was 11.0 (5.6) days, and the perioperative mortality rate was 0.2% (1 patient). The postop complication rate was 28.2%, with 13.5% for Grade 1-2 complications and 14.7% for Grade 3-4 complications. Common complications included abdominal abscess (5.4%), ileus (4.6%), and anastomotic leak (4.6%). Over a mean follow-up of 60 months, there was a total mortality of 34.9% and mortality from tumour recurrence or metastasis was 27.4%. Factors that significantly and independently affected CSS include BMI (hazards ratio 2.30, 95% CI 1.27-4.17, p = 0.006) and N stage (HR 2.97, 95% CI 1.48-5.97, p = 0.002). Overall, this study demonstrated the safety and feasibility of radical CRC surgery for patients over 80 years, with BMI and N stage being independent factors that influence CSS.

Image: PD

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