Salvatore Giordano

The SCARE Statement: Consensus-based surgical case report guidelines

INTRODUCTIONnCase reports have been a long held tradition within the surgical literature. Reporting guidelines can improve transparency and reporting quality. However, recent consensus-based guidelines for case reports (CARE) are not surgically focused. Our objective was to develop surgical case report guidelines.nnnMETHODSnThe CARE statement was used as the basis for a Delphi consensus. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. A multidisciplinary group of surgeons and others with expertise in the reporting of case reports were invited to participate. In round one, participants stated how each item of the CARE statement should be changed and what additional items were needed. Revised and additional items from round one were put forward into a further round, where participants voted on the extent of their agreement with each item, using a nine-point Likert scale, as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.nnnRESULTSnIn round one, there was a 64% (38/59) response rate. Following adjustment of the guideline with the incorporation of recommended changes, round two commenced and there was an 83% (49/59) response rate. All but one of the items were approved by the participants, with Likert scores 7-9 awarded by >70% of respondents. The final guideline consists of a 14-item checklist.nnnCONCLUSIONnWe present the SCARE Guideline, consisting of a 14-item checklist that will improve the reporting quality of surgical case reports.

The STROCSS statement: Strengthening the Reporting of Cohort Studies in Surgery

INTRODUCTIONnThe development of reporting guidelines over the past 20 years represents a major advance in scholarly publishing with recent evidence showing positive impacts. Whilst over 350 reporting guidelines exist, there are few that are specific to surgery. Here we describe the development of the STROCSS guideline (Strengthening the Reporting of Cohort Studies in Surgery).nnnMETHODS AND ANALYSISnWe published our protocol apriori. Current guidelines for case series (PROCESS), cohort studies (STROBE) and randomised controlled trials (CONSORT) were analysed to compile a list of items which were used as baseline material for developing a suitable checklist for surgical cohort guidelines. These were then put forward in a Delphi consensus exercise to an expert panel of 74 surgeons and academics via Google Forms.nnnRESULTSnThe Delphi exercise was completed by 62% (46/74) of the participants. All the items were passed in a single round to create a STROCSS guideline consisting of 17 items.nnnCONCLUSIONnWe present the STROCSS guideline for surgical cohort, cross-sectional and case-control studies consisting of a 17-item checklist. We hope its use will increase the transparency and reporting quality of such studies. This guideline is also suitable for cross-sectional and case control studies. We encourage authors, reviewers, journal editors and publishers to adopt these guidelines.

Preferred reporting of case series in surgery; the PROCESS guidelines

INTRODUCTIONnCase series have been a long held tradition within the surgical literature and are still frequently published. Reporting guidelines can improve transparency and reporting quality. No guideline exists for reporting case series, and our recent systematic review highlights the fact that key data are being missed from such reports. Our objective was to develop reporting guidelines for surgical case series.nnnMETHODSnA Delphi consensus exercise was conducted to determine items to include in the reporting guideline. Items included those identified from a previous systematic review on case series and those included in the SCARE Guidelines for case reports. The Delphi questionnaire was administered via Google Forms and conducted using standard Delphi methodology. Surgeons and others with expertise in the reporting of case series were invited to participate. In round one, participants voted to define case series and also what elements should be included in them. In round two, participants voted on what items to include in the PROCESS guideline using a nine-point Likert scale to assess agreement as proposed by the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) working group.nnnRESULTSnIn round one, there was a 49% (29/59) response rate. Following adjustment of the guideline with incorporation of recommended changes, round two commenced and there was an 81% (48/59) response rate. All but one of the items were approved by the participants and Likert scores 7-9 were awarded by >70% of respondents. The final guideline consists of an eight item checklist.nnnCONCLUSIONnWe present the PROCESS Guideline, consisting of an eight item checklist that will improve the reporting quality of surgical case series. We encourage authors, reviewers, editors, journals, publishers and the wider surgical and scholarly community to adopt these.

Linear Stapler Technique May Be Safer than Circular in Gastrojejunal Anastomosis for Laparoscopic Roux-en-Y Gastric Bypass: A Meta-analysis of Comparative Studies

The technique of choice for gastrojejunostomy (GJ) during laparoscopic Roux-en-Y gastric bypass (LRYGB) for morbid obesity is controversial. We performed a meta-analysis comparing linear versus circular stapler technique to evaluate this issue. A systematic literature search was performed. Primary outcomes were gastrojejunal leak and stricture. Secondary outcomes were operative time, length of hospital stay, post-operative bleeding, wound infection, marginal ulcers and estimated weight loss. Eight studies involving 1,321 patients were retrieved and included in the present study. A significantly decreased risk of GJ stricture was observed after using linear versus circular stapler (RR, 0.34; 95% CI, 0.12–0.93; pu2009=u20090.04). Wound infection risk (RR, 0.38; 95% CI, 0.22–0.67; pu2009=u20090.0008) and operative time (MD, −24.18; 95% CI, −35.31, −13.05; pu2009<u20090.0001) were significantly reduced by using linear stapling. No significant differences were observed in the other outcome end-points. The use of the linear stapler compared with circular stapler for GJ during LRYGB for morbid obesity may be associated with a reduced risk of anastomosis stricture and wound infection, as well as with a shorter operative time.

Povidone-Iodine Combined With Antibiotic Topical Irrigation to Reduce Capsular Contracture in Cosmetic Breast Augmentation

BACKGROUNDnAntibacterial lavage with topical antibiotics may reduce the occurrence of capsular contracture (CC) in breast augmentation.nnnOBJECTIVESnThe authors investigate the efficacy of povidone-iodine combined with antibiotic irrigation in reducing the CC rate.nnnMETHODSnThe charts of 330 consecutive women who underwent cosmetic breast augmentation during 2 different periods (group A: 2004-2009, n = 165; group B: 2009-2010, n = 165) were retrospectively reviewed. All patients in the series underwent augmentation with the same surgeon (A.S.) via the inframammary approach and dual-plane pocket. In group A, patients received a single perioperative dose of 1.5 g of intravenous cephalothin and 750 mg of oral cephalexin twice a day for 7 days after discharge. In group B, patients perioperatively received 750 mg of intravenous cefuroxime, and each implant and pocket were irrigated with 25 mL of a 10% povidone-iodine solution mixed with 750 mg of cefuroxime and 80 mg of gentamicin diluted in 15 mL of 0.9% sodium chloride solution. After discharge, patients received 500 mg of oral levofloxacin once a day for 5 days. Postoperative complications included occurrence of infection, hematoma, seroma, and CC.nnnRESULTSnMean (SD) postoperative follow-up in groups A and B was 24 (+/- 13) months and 22 (+/- 3) months, respectively. The postoperative superficial wound infection rate was 1.8% and 1.2%, the seroma rate was 1.8% and 1.2%, and the hematoma rate was 0.6% and 1.2% in groups A and B, respectively. Ten CC cases (Baker grade 3 or 4) in group A and 1 in group B were reported (6% vs 0.6%; P = .006).nnnCONCLUSIONSnPovidone-iodine and antibiotic irrigation in cosmetic breast augmentation yielded a lower CC rate than standard perioperative antibiotics in this series of patients.

Bariatric surgery in elderly patients: a systematic review

Controversy exists regarding the effectiveness and safety of bariatric/metabolic surgery in elderly patients. We performed a systematic review on this issue in patients aged 60 years or older. MEDLINE, Cochrane Library, Embase, Scopus, and Google Scholar were searched until August 2015 for studies on outcomes of bariatric surgery in elderly patients. The results were expressed as pooled proportions (%) with 95% confidence intervals. Heterogeneity across the studies was evaluated by the I2 test, and a random-effects model was used. Twenty-six articles encompassing 8,149 patients were pertinent with this issue and included data on bariatric surgery outcomes in elderly population. Fourteen patients died during the 30-day postoperative period, with a pooled mortality of 0.01%. Pooled overall complication rate was 14.7%. At 1-year follow-up, pooled mean excess weight loss was 53.77%, pooled diabetes resolution was 54.5%, and pooled hypertension resolution was 42.5%, while pooled lipid disorder resolution was 41.2%. Outcomes and complication rates of bariatric surgery in patients older than 60 years are comparable to those in a younger population, independent of the type of procedure performed. Patients should not be denied bariatric surgery because of their age alone.

The Need for a Specific Risk Prediction System in Native Valve Infective Endocarditis Surgery

The need for a specific risk score system for infective endocarditis (IE) surgery has been previously claimed. In a single-center pilot study, preliminary to future multicentric development and validation, bivariate and multivariate (logistic regression) analysis of early postoperative mortality predictors in 440 native valve IE patients were performed. Mathematical procedures assigned scores to the independent predictors emerged (AUC of the ROC curve: 0.88). Overall mortality was 9.1%. Six predictors were identified and assigned scores, including age (5–13 points), renal failure (5), NYHA class IV (9), critical preoperative state (11), lack of preoperative attainment of blood culture negativity (5), perivalvular involvement (5). Four risk classes were drawn ranging from “very low risk” (≤5 points, mean predicted mortality 1%), and to “very high risk” (≥20 points, 43% mortality). IE-specific risk stratification models are both needed, as disease-specific factors (e.g., cultures, abscess), beside the generic ones (e.g., age, renal impairment) affect mortality, and feasible.

Effectiveness of intravesical hyaluronic acid/chondroitin sulfate in recurrent bacterial cystitis: a randomized study

Introduction and hypothesisThe glycosaminoglycan hyaluronic acid (HA) protects the urothelium; damage may increase bacterial adherence and infection risk. This study evaluated the effect of intravesical HA in recurrent bacterial cystitis (RBC).MethodsWomen with RBC were randomized to intravesical HA 800xa0mg and chondroitin sulfate (CS) 1xa0g (IALURIL®, IBSA) in 50xa0mL of saline solution once weekly for 4xa0weeks then once every 2xa0weeks twice more (group 1) or long term antibiotic prophylaxis using sulfamethoxazole 200xa0mg and trimethoprim 40xa0mg once weekly for 6xa0weeks (group 2; control). Evaluations included: cystitis recurrence at 2 and 12xa0months; subjective pain symptoms (visual analog scale [VAS]); 3xa0day voiding; sexual function; quality of life (Kings Health Questionnaire [KHQ]); frequency symptoms/frequency symptoms (PUF symptom scale); and maximum cystometric capacity (MCC). Means ± standard deviations were reported, with Mann-Whitney test for between-group comparison (significance Pu2009<u2009.05).ResultsOf 28 women (mean age 60u2009±u200913xa0y) randomized, 26 completed follow-up (mean follow-up 11.5xa0mo). Group 1 showed a significant improvement in all evaluations; cystitis recurrence (1u2009±u20091.2 versus 2.3u2009±u20091.4, Pu2009=u2009.02); 3-day voiding (mean 17.8u2009±u20093.5 vs 24.2u2009±u20098.3, Pu2009=u2009.04); symptom VAS (1.6u2009±u20090.8 vs 7.8u2009±u20091.6, Pu2009<u2009.001); PUF score (11.2u2009±u20092.7 vs 19.6u2009±u20092.2, Pu2009<u2009.001), KHQ score (18.4u2009±u20097.2 vs 47.3u2009±u200913.6, Pu2009<u2009.001), and MCC (380u2009±u200978 vs 229u2009±u200951xa0mL, Pu2009<u2009.001) vs group 2 at 12xa0mo. No adverse effects were recorded.ConclusionsIntravesical HA and CS in combination significantly reduced cystitis recurrence and improved urinary symptoms, quality of life, and cystometric capacity in RBC patients at 12xa0mo follow-up versus antibiotic prophylaxis. Study limitations include a small sample and relatively short follow-up.

Desire for Body Contouring Surgery After Bariatric Surgery

BACKGROUNDnThere is disparity between the number of postbariatric surgery subjects who desire body contouring and those who receive it due to lack of resources or insurance criteria.nnnOBJECTIVESnThe authors evaluate the desire for body contouring after bariatric surgery and its relationship with demographic patient characteristics.nnnMETHODSnThree hundred sixty patients who had undergone bariatric surgery procedures >1 year previously completed a questionnaire designed by the surgical team to analyze each patients desire for body contouring by area (face, upper arm, upper back, chin/neck, chest/breast, waist/abdomen, lower back, rear/buttock), scored from 0 to 3 (do not want, want somewhat, want, want a great deal). Data were compared with patient characteristics, postoperative body mass index (BMI), amount of weight loss, and BMI difference (ΔBMI).nnnRESULTSnMost patients desired body contouring surgery, with high or very high desire for waist/abdomen (62.2%), upper arm (37.6%), chest/breast (28.3%), and rear/buttock (35.6%) contouring. Many patients (36.4%) cited very high expectations for how body contouring might change their appearance. Patients >50 years old and >3 years postsurgery had a significantly lower desire. Patients with a ΔBMI >10 and with a weight loss >20 kg showed a significantly stronger overall desire for body contouring compared with other groups.nnnCONCLUSIONSnMost patients desire body contouring surgery after bariatric surgery, and our multivariate analysis showed a significant positive association between female sex, younger age, amount of weight loss, and ΔBMI with desire for body contouring.

Physical discomfort due to redundant skin in post-bariatric surgery patients

Massive weight loss after bariatric surgery leads to excess skin with functional and aesthetic impairments. The aim of this study was to evaluate the prevalence of excess skin after bariatric surgery and identify any relationship with pre- and postoperative characteristics. A total of 360 patients who had undergone bariatric surgery procedures were asked to complete a questionnaire designed by the surgical team at least 1 year after surgery. This questionnaire was planned to estimate any impairment due to redundant skin, which was graded according to a visual analogue scale (VAS, 0--0). Mean (standard deviation, SD) age of 110 males and 250 females was 51.2 (10.8) years. Mean preoperative body mass index (BMI) was 45.7 (6.4) kg m(-2) and mean postoperative BMI at follow-up was 33.6 (6.0) kg m(-2). After a mean follow-up of 56.1 (43.6) months, the mean weight loss was 35.2 (18.8) kg. Most patients (92.8%) reported problems with redundant skin, especially on the abdomen, upper arms and rear/buttocks, which impaired daily physical activity in half of them. Excess skin was associated with female gender (β=-13.56, 95% confidence interval (CI) -16.81 to -10.32, p<0.0001), weight loss (β=0.21, 95% CI 0.12-0.29, p<0.0001) and ΔBMI (β=0.21, 95% CI 0.12-0.29, p<0.0001) at multivariate analysis. Patients with a ΔBMI>20 kg m(-2) showed a significantly surplus skin discomfort compared to ΔBMI≤5 and 550 kg showed a significantly redundant skin discomfort compared to weight loss<20 kg (p<0.001). Weight loss after bariatric surgery reduces the medical risks of obesity but psychosocial and functional problems often remain due to the surplus skin. Our data suggest that a ΔBMI≤10 kg m(-2) and weight loss>20 kg, not BMI alone, might be taken into consideration as cut-off values for developing score systems with the intention to apply evidence-based indications for the surgical management of post-bariatric impairments.