Andry Irawan

Introduction: Iatrogenic cervical esophageal perforation (ICEP) represents a rare and challenging surgical complication that results in significant morbidity and mortality. This is a case report of a cervical esophageal fistula that resulted from an iatrogenic perforation following thyroid surgery, treated with surgical repair followed by negative pressure wound therapy (NPWT). Presentation of case: A 43-year-old female was presented with an infected post-total thyroidectomy and bilateral radical neck dissection two weeks prior. Esophagography revealed contrast leakage from the anterolateral aspect of the esophagus at the level of C7-T1. Surgical debridement exposed large (4 × 1 cm) esophageal damage. The esophageal repair was performed using a sternocleidomastoids flap reinforced with BioGlue® followed by placement of a feeding tube through a gastrostomy. Subsequent mucus leakage was observed two weeks after the repair. Conservative approach using NPWT was used to promote wound closure. Over a 3-week period, serial imaging demonstrated fistula closure and complete wound healing by 8 weeks. Discussion: A delay in diagnosis and treatment for esophageal perforation leads to severe complications, highlighting the need for standardized treatment algorithms. Larger perforations illustrated in this case report require primary repair with muscle flaps. When reconstructive surgery fails, a follow-up conservative therapy utilizing proper NPWT was able to heal the leakage. Conclusion: This case report illustrates rare but devastating potential complications from a commonly performed oncologic surgery. The involvement of a multidisciplinary team from the very first identification of surgical complications is crucial for ensuring proper treatment. Highlights:

Background: The use of digital online teaching media in improving the surgical skills of medical students is indispensable, yet it is still not widely explored objectively. The first-person–view online teaching method may be more effective as it provides more realism to surgical clerkship students in achieving basic surgical skills. Objective: This study aims to objectively assess the effectiveness of the first-person–view live streaming (LS) method using a GoPro camera compared to the standard face-to-face (FTF) teaching method in improving simple wound suturing skills in surgical clerkship students. Methods: A prospective, parallel, nonblinded, single-center, randomized controlled trial was performed. Between January and April 2023, clerkship students of the Department of Surgery, Pelita Harapan University, were randomly selected and recruited into either the LS or FTF teaching method for simple interrupted suturing skills. All the participants were assessed objectively before and 1 week after training, using the direct observational procedural skills (DOPS) method. DOPS results and poststudy questionnaires were analyzed. Results: A total of 74 students were included in this study, with 37 (50%) participants in each group. Paired analysis of each participant’s pre-experiment and postexperiment DOPS scores revealed that the LS method’s outcome is comparable to the FTF method’s outcome (LS: mean 27.5, SD 20.6 vs FTF: mean 24.4, SD 16.7; P=.48) in improving the students’ surgical skills. Conclusions: First-person–view LS training sessions could enhance students’ ability to master simple procedural skills such as simple wound suturing and has comparable results to the current FTF teaching method. Teaching a practical skill using the LS method also gives more confidence for the participants to perform the procedure independently. Other advantages of the LS method, such as the ability to study from outside the sterile environment, are also promising. We recommend improvements in the audiovisual quality of the camera and a stable internet connection before performing the LS teaching method.

Introduction: Acute appendicitis is the most common surgical emergency in pregnant women. There has been a wide variance in clinical practice worldwide, with some favoring an antibiotic-only approach while others prefer surgery as the first-line management. Therefore, we designed the current analysis to synthesize the available evidence on the efficacy and safety of antibiotics versus surgery management. Methods: We searched PubMed, Scopus, EuropePMC, and Cochrane Central from March 4, 1904 until November 25, 2022, to look for studies comparing antibiotics and surgery in pregnant patients with acute appendicitis. We only included studies that provided a comparison between the two treatments. Measured outcomes included preterm delivery, fetal loss, maternal death, and complications, defined as those arising from the pathological processes or treatment, including, but not limited to, sepsis or septic shock, pneumonia, venous thromboembolism (VTE), and surgical site infection. The results were compared using an odds ratio and 95% confidence interval. We also performed a sensitivity analysis by excluding studies with a serious risk of bias. Results: We included five non-randomized studies for the analysis. We found that patients in the antibiotic group had a lower risk of preterm labor (OR 0.63 [95% CI 0.43–0.92]; p 0.02) but a higher risk of complications (OR 1.79 [95% CI 1.19–2.69]; p 0.005). We did not find any difference in the other outcomes. Conclusion: The increased risk of complications should caution clinicians about using antibiotics as the first-line management. More studies are required to identify patients who would benefit the most before antibiotics could be adopted as a treatment for acute appendicitis in pregnant patients.

Introduction: Acute appendicitis is the most common surgical emergency in pregnant women. There has been a wide variance in clinical practice worldwide, with some favoring an antibiotic-only approach while others prefer surgery as the first-line management. Therefore, we designed the current analysis to synthesize the available evidence on the efficacy and safety of antibiotics versus surgery management. Methods: We searched PubMed, Scopus, EuropePMC, and Cochrane Central from March 4, 1904 until November 25, 2022, to look for studies comparing antibiotics and surgery in pregnant patients with acute appendicitis. We only included studies that provided a comparison between the two treatments. We included preterm delivery, fetal loss, maternal death, and complications as outcomes. The results were compared using an odds ratio and 95% confidence interval. We also performed a sensitivity analysis by excluding studies with a serious risk of bias. Results: We included five non-randomized studies for the analysis. We found that patients in the antibiotic group had a lower risk of preterm labor (OR 0.63 [95% CI 0.43–0.92]; p 0.02) but a higher risk of complications (OR 1.79 [95% CI 1.19–2.69]; p 0.005). We did not find any difference in the other outcomes. Conclusion: The increased risk of complications should caution clinicians about using antibiotics as the first-line management. More studies are required to identify patients who would benefit the most before antibiotics could be adopted as a treatment for acute appendicitis in pregnant patients.

Introduction: Pancreatic injury is a rare case, caused by blunt or sharp trauma. Difficulty in making diagnose on pancreatic trauma cases are associated with high mortality, and the treatment can be either operative or conservatively. However, It is still unclear which treatment is more favorable.Case: We present 2 cases of Grade III pancreatic injury with stable hemodynamic who suffered bicycle accident. First case, 12-year-old boy complaining severe pain on the upper left abdomen (VAS 9-10) and get worsening by time, with vomiting. The patient underwent distal Pancreatectomy-Splenectomy. Second case, 8-year-old boy complaining of pain on the upper left abdomen (VAS 6-7) without extension on whole abdominal region with vomiting and fever. The patient was treated conservatively. In both cases, patient was discharged with improvement. However, about 3 months later patients who were treated conservatively developed into a pseudocyst.Conclusion: The selection of management in grade III pancreatic injury can be operative or conservative depending on clinical findings such as hemodynamic condition and the quality of abdominal pain. But the occurrence of pseudocysts pancreas is another surgical challenge.