Oliver J. Warren

What does leadership in surgery entail

Background:  Leadership is not formally taught at any level in surgical training; there are no mandatory leadership courses or qualifications for trainees or specialists, and leadership performance is rarely evaluated within surgical appraisal or assessment programmes.

The Neurocognitive Enhancement of Surgeons: An Ethical Perspective

Neurocognitive enhancement is a rapidly expanding scientific field. The vast ethical implications of this developing field for surgical practice have yet to be considered within the literature. This article outlines the reasons surgeons may, in the near future, consider using neurocognitive enhancement and addresses the resulting significant ethical implications of this. We do not seek to support or denounce the potential role of neurocognitive enhancement in surgeons, but to stimulate a debate, which, with ever-increasing levels of stimulant use in schools and colleges, and with a pharmaceutical industry driving the creation of new neuroactive products, has now become a necessity.

Do miniaturized extracorporeal circuits confer significant clinical benefit without compromising safety? A meta-analysis of randomized controlled trials.

Miniaturized extracorporeal circulation (mECC) attempts to reduce the adverse effects of conventional extracorporeal circulation (CECC) bypass. However, the potential benefits remain unclear and safety concerns persist. A systematic literature review identified 29 studies incorporating 2,355 patients: 1,181 (50.1%) who underwent cardiac surgery with CECC and 1,174 (49.9%) with mECC. These were meta-analyzed using random effects modeling. Heterogeneity, subgroup analysis, and risk of bias were assessed. Primary endpoints were 30-day mortality, neurovascular compromise, and end organ dysfunction. Secondary endpoints were length of stay and transfusion burden. Miniaturized extracorporeal circulation significantly reduced postoperative arrhythmias (p = 0.03), but no significant difference in 30-day mortality, neurocognitive disturbance, cerebrovascular events, renal failure, or myocardial infarction was identified. Miniaturized extracorporeal circulation also significantly reduced mean blood loss (p < 0.00001) and number of patients transfused (p < 0.00001); however, duration of hospitalization, units transfused per patient, chest tube drainage, and revision for rebleeding remained unchanged. Subgroup analysis of larger studies (10 studies, n ≥ 31) showed mECC to significantly reduce ventilation period, hospital stay, and intensive care unit (ICU) stay. Similarly, a significant reduction in neurocognitive disturbance was seen in studies with closely matched demographic groups. Miniaturized extracorporeal circulation is not associated with increased cerebrovascular injury and may confer an advantage, reducing postoperative arrhythmia, blood loss, and transfusion burden.

How can we build mentorship in surgeons of the future

Background:  In the past, surgical training has been based on traditional apprenticeship model of mentoring. To cope with the rapidly changing environment of modern surgery, the mentoring process may require significant modernization.

Systemic leukofiltration does not attenuate pulmonary injury after cardiopulmonary bypass.

Pulmonary injury mediated by activated leukocytes is a recognized complication of cardiopulmonary bypass. The aim of this paper is to systematically analyze the effects of systemic leukofiltration within the cardiopulmonary bypass circuit on pulmonary injury and related clinical outcomes. We performed a systematic search to identify randomized controlled trials reporting on the effects of systemic leukofiltration on respiratory parameters. Random effect meta-analytical techniques were applied to identify differences in outcomes between the two groups. Sensitivity and subgroup analyses were undertaken to evaluate study heterogeneity. Incorporating 995 patients, 21 studies satisfied the inclusion criteria. Systemic leukofiltration significantly increased the PaO2/FiO2 ratio within 12 hours of bypass cessation, (weighted mean difference (WMD), 25.97; 95% confidence interval (CI), 3.41–48.53; p = 0.02) but this effect was lost by 24 hours (WMD, 12.98; 95% CI, −7.93–33.89; p = 0.22). Leukofiltration significantly reduced the duration of ventilatory support postoperatively (WMD, −2.11 hours; 95% CI, −0.65 to −3.58; p = 0.005), but had no impact on postoperative chest infection, intensive care length of stay or hospital length of stay. The heterogeneity of the included studies was high, due to poor quality study design and failure to include patients at high risk of pulmonary complications. Systemic leukofiltration may attenuate bypass-related lung injury in the early postoperative period, but this does not seem to translate to clinically significant differences in outcomes.

How minimalized extracorporeal circulation compares with the off-pump technique in coronary artery bypass grafting

Recognition of the adverse effects of conventional extracorporeal circulation (CECC) led to the development of alternative technologies and techniques to minimize their impact while maintaining circulation during coronary artery bypass grafting (CABG). Off-pump coronary artery bypass (OPCAB) grafting has become established as one such alternative and more recently minimalized extracorporeal circulation (MECC) circuits have been developed with the aim of providing circulatory support while minimizing the interface between blood and the foreign surfaces of the circuit that initiates the associated adverse effects of CECC. Recently, some authors have suggested that MECC may be an alternative to OPCAB in patients undergoing CABG; the aim of this article is to systematically analyze and compare the impact of CABG with MECC with that of OPCAB, studying the adverse outcomes related to CECC. We performed a systematic search to identify all studies directly comparing OPCAB and MECC. Endpoints were subcategorized into four key areas of interest: length of stay (LOS), hemorrhage, cerebrovascular injury, and 30-day mortality. Random effect modeling techniques were applied to identify differences in outcomes between the two groups. Six studies fulfilled the inclusion criteria, incorporating 2,072 patients of whom 930 underwent OPCAB and 1,142 underwent revascularization supported by MECC. We found no statistically significant difference in hospital or intensive care unit (ICU) LOS, blood loss, mean number of patients transfused, neurocognitive disturbance, or 30-day mortality between the two groups but a trend toward an increased number of cerebrovascular events in the MECC group was observed. The number of studies comparing these alternative techniques for coronary revascularization is small, and there is a lack of high-quality data. Currently, there seems little difference between MECC and OPCAB but larger randomized controlled trials focusing on high-risk patients are required.

Recombinant activated factor VII in cardiac surgery – first, do no harm

Letter to the editor We read with interest Heise et als case report and review of the literature regarding the use of recombinant activated factor VII (rFVIIa) in patients with ventricular assist devices (VAD) [1]. Whilst we welcome the addition to the literature in this area, there are two key areas regarding this relatively novel haemostatic agent that we felt the authors had failed to address appropriately, and that may therefore mislead the practicing cardiac surgeon.

Skeletonization of radial and gastroepiploic conduits in coronary artery bypass surgery

The use of a skeletonized internal thoracic artery in coronary artery bypass graft surgery has been shown to confer certain advantages over a traditional pedicled technique, particularly in certain patient groups. Recent reports indicate that radial and gastroepiploic arteries can also be harvested using a skeletonized technique. The aim of this study is to systematically review the available evidence regarding the use of skeletonized radial and gastroepiploic arteries within coronary artery bypass surgery, focusing specifically on its effect on conduit length and flow, levels of endothelial damage, graft patency and clinical outcome. Four electronic databases were systematically searched for studies reporting the utilisation of the skeletonization technique within coronary revascularisation surgery in humans. Reference lists of all identified studies were checked for any missing publications. There appears to be some evidence that skeletonization may improve angiographic patency, when compared with pedicled vessels in the short to mid-term. We have found no suggestion of increased complication rates or increased operating time. Skeletonization may increase the length of the conduit, and the number of sequential graft sites, but no clear clinical benefits are apparent. Our study suggests that there is not enough high quality or consistent evidence to currently advocate the application of this technique to radial or gastroepiploic conduits ahead of a traditional pedicled technique.