Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

Impact of Residency Training Level on the Surgical Quality Following General Surgery Procedures

Objective

To investigate the safety of surgical performance by residents of different training level performing common general surgical procedures.

Methods

Data were consecutively collected from all patients undergoing general surgical procedures such as laparoscopic cholecystectomy, laparoscopic appendectomy, inguinal, femoral and umbilical hernia repair from 2005 to 2011 at the Department of Surgery of the University Hospital of Zurich, Switzerland. The operating surgeons were grouped into junior residents, senior residents and consultants. The comprehensive complication index (CCI) representing the overall number and severity of all postoperative complications served as primary safety endpoint. A multivariable linear regression analysis was used to analyze differences between groups. Additionally, we focused on the impact of senior residents assisting junior residents on postoperative outcome comparing to consultants.

Results

During the observed time, 2715 patients underwent a general surgical procedure. In 1114 times, a senior resident operated and in 669 procedures junior residents performed the surgery. The overall postoperative morbidity quantified by the CCI was for consultants 5.0 (SD 10.7), for senior residents 3.5 (8.2) and for junior residents 3.6 (8.3). After adjusting for possible confounders, no difference between groups concerning the postoperative complications was detected. There is also no difference in postoperative complications detectable if junior residents were assisted by consultants then if assisted by senior residents.

Discussion

Patient safety is ensured in general surgery when performed by surgical junior residents. Senior residents are able to adopt the role of the teaching surgeon in charge without compromising patients’ safety.

     

Transvaginal uterosacral ligament hysteropexy: a video tutorial

Introduction and hypothesis

Uterine-sparing procedures could be attractive in patients concerned about fertility preservation and corporeal image changes. Transvaginal uterosacral ligaments (USLs) hysteropexy can provide a mesh-free technique for uterine suspension. This video is intended to serve as a tutorial for surgical steps.

Methods

A 38-year-old woman with symptomatic stage III POP desired preserving fertility. After proper counseling, the patient was admitted for vaginal hysteropexy through bilateral high USL suspension according to the featured technique.

Results

Prolapse repair was successfully achieved without complications. We had already published a series of 20 cases that confirmed that transvaginal USLs hysteropexy is a promising technique for correcting genital prolapse with uterus preservation.

Conclusion

Transvaginal USLs hysteropexy provides a feasible technique for apical support without the use of prosthetic material. This procedure could be attractive to women who desire a uterine-sparing surgical option.

     

Lingual orthodontics for children and adolescents: improvement of the indirect bonding protocol

Introduction

Demineralization of the dental enamel is a finding associated with fixed orthodontic treatment. When an indirect bonding procedure is used in children and adolescents the area beneath the bracket base may be affected.

Aim

To evaluate if the addition of an extra layer of a hydrophilic resin, to a conventional indirect bonding protocol, can reduce the incidence of demineralization beneath the bracket base.

Methods

40 patients under 18 years of age were treated with completely customized lingual appliances. Two different bonding protocols were used either with or without the application of an additional layer of hydrophilic resin. Demineralization beneath the bracket base, after de-bonding, was evaluated by standardized intra-oral photographs.

Results

The addition of an extra layer of a hydrophilic resin helps to reduce the number of demineralized areas beneath the bracket bases significantly (three times less). The severity of the few remaining defects were minor and without any clinical consequence.

Conclusion

When bonding a completely customized lingual appliance in children and adolescents, an extra layer of a hydrophilic resin should be added to the teeth.

     

Transvaginal native-tissue repair of enterocele

Introduction and hypothesis

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

Methods

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

Conclusions

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

     

Komplikationsmanagement im Internet Marketing

Background

New patients come more and more often over the internet; therefore internet marketing plays an increasingly important role.

Question

How can physicians build an effective internet marketing strategy and avoid complications?

Method

Selection and authorization of a reputable agency.

Results

New customer acquisition through high visibility in the internet, at the same time increasing the image and awareness.

Conclusions

In the overall “marketing mix” internet marketing has become indispensable to physicians who want to be successful. Those who are well positioned in Google are well known by their target audience and thus receive a higher response.

     

Mentorship in anesthesia: a survey of perspectives among Canadian anesthesia residents

Purpose

Mentorship is important for professional and academic growth; however, the role of mentorship in anesthesia is still being defined. We surveyed Canadian anesthesia residents to explore their perceptions of mentorship relationships.

Methods

We administered a 20-item cross-sectional survey to program directors and anesthesia residents in all Canadian departments of anesthesia. Program directors were asked about their mentorship programs, and residents were asked about their perceptions of benefits and barriers to effective mentoring.

Results

Sixteen of 17 (94%) program directors and 189 of 585 (32%) anesthesia residents responded to our survey. While 143 of 180 (79%) residents agreed that mentorship was beneficial to overall success as an anesthesiologist, only 11 of 16 (69%) program directors reported formal mentorship as part of their residency program, and only 119 of 189 (63%) residents reported access to a mentor. Barriers reported by residents included insufficient time with mentors, lack of formalized meeting times and objectives, mentor-mentee incompatibility (personal or professional), and lack of resident choice in mentor selection.

Conclusion

Our study confirms that, despite positive perceptions among residents, mentorship remains underutilized in anesthesia programs. We identify barriers to effective mentorship, including the need to consider resident choice as a means to improve formal anesthesia mentorship programs.

     

Predictors of intra-operative blood loss and blood transfusion in orthognathic surgery: a retrospective cohort study in 92 patients

Background

Patients undergoing orthognathic procedures can require blood transfusions. The objectives of this study were to evaluate the predictors of intra-operative blood loss in patients undergoing orthognathic procedures and the transfusion rates and practices of our institution.

Materials and methods

This retrospective study included 92 patients who underwent the following four types of orthognathic procedures: Group 1, bimaxillary; Group 2, bimaxillary with bone grafts; Group 3, LeFort I osteotomies; and Group 4, LeFort I osteotomies with bone grafts. The intra-operative blood loss, operative time, age, gender and pre- and post-operative HGB and HCT were assessed.

Results

The mean blood loss for all groups was 650±397.8 mL, and there were differences in blood loss between the four groups (p = 0.211). The mean operative time was 5 hours and 32 minutes. There were no differences in intra-operative blood loss between the genders or the BMI categories. The operative time was moderately correlated with the intra-operative blood loss (p < 0.001, r =0.332). Eighteen of the 92 patients (19.5%) received blood transfusions. The mean intra-operative blood loss was higher among the patients who received transfusions (p < 0.001).

Conclusions

The only predictor of intra-operative blood loss was operative time. The observed transfusion rate was higher than those that have been reported for similar procedures; thus, our institution needs to revisit our transfusion policy and use more time-efficient techniques in the operating room.

     

Qualitätssicherung in Laser- und Plasmamedizin

Background

Maxillofacial surgery is constantly developing and introducing new medical technology, such as laser and plasma devices.

Objective

Process-oriented quality management by continuing postgraduate education in new technological procedures.

Material and methods

Compilation of essential guidelines and quality-oriented educational programs in laser and plasma medicine.

Results

The university based continuing education for a diploma in aesthetic laser medicine (DALM) is a postgraduate study program accredited in 1999 by the state authorities and based on an interdisciplinary, multicenter, industry-independent and scientific curriculum that leads to board certification.

Conclusion

The DALM program is an important instrument for process-oriented quality management in plasma and aesthetic laser medicine.

     

Patellaformen

Background

Patella height is discussed as a possible factor in the development of osteoarthritis of the knee.

Methods

PubMed literature search

Results

Contradictory results are found in the literature.

Conclusion

According to the literature, there is currently no evidence that abnormal patella height can induce osteoarthritis of the knee.

     

Repair of a vesicouterine fistula following cesarean section

Introduction and hypothesis

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

Methods

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

Results

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

Conclusions

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

     

Global Estimation of Surgical Procedures Needed for Forcibly Displaced Persons

Introduction

Sixty million people were displaced from their homes due to conflict, persecution, or human rights violations at the end of 2014. This vulnerable population bears a disproportionate burden of disease, much of which is surgically treatable. We sought to estimate the surgical needs for forcibly displaced persons globally to inform humanitarian assistance initiatives.

Methods

Data regarding forcibly displaced persons, including refugees, internally displaced persons (IDPs), and asylum seekers were extracted from United Nations databases. Using the minimum proposed surgical rate of 4669 procedures per 100,000 persons annually, global, regional, and country-specific estimates were calculated. The prevalence of pregnancy and obstetric complications were used to estimate obstetric surgical needs.

Results

At least 2.78 million surgical procedures (IQR 2.58–3.15 million) were needed for 59.5 million displaced persons. Of these, 1.06 million procedures were required in North Africa and the Middle East, representing an increase of 50 % from current unmet surgical need in the region. Host countries with the highest surgical burden for the displaced included Syria (388,000 procedures), Colombia (282,000 procedures), and Iraq (187,000). Between 4 and 10 % of required procedures were obstetric surgical procedures. Children aged <18 years made up 52 % of the displaced, portending a substantial demand for pediatric surgical care.

Conclusion

Approximately three million procedures annually are required to meet the surgical needs of refugees, IDPs, and asylum seekers. Most displaced persons are hosted in countries with inadequate surgical care capacity. These figures should be considered when planning humanitarian assistance and targeted surgical capacity improvements.

     

Development of Minimally Invasive Pancreatic Surgery: an Evidence-Based Systematic Review of Laparoscopic Versus Robotic Approaches

Introduction

Laparoscopic and robotic surgery of the pancreas has only recently emerged as viable treatment options for benign and malignant disease. This review seeks to evaluate the current body of evidence on these approaches to pancreaticoduodenectomy and distal pancreatectomy.

Methods

A systematic review of large published series was performed utilizing the PubMed search engine.

Results

Based on these reports, both the laparoscopic and robotic techniques for these complex procedures appear to be safe and effective, if performed by high volume experienced pancreatic surgeons. The advantages of each approach are highlighted, emphasizing the data available on the learning curve and potential dissemination.

Conclusions

Both minimally invasive approaches to pancreatic resection are safe and feasible.

     

Transvaginal uterosacral ligament suspension for posthysterectomy vaginal vault prolapse repair

Introduction and hypothesis

Posthysterectomy vaginal vault prolapse repair represents a challenge for urogynecologists. Surgical management can be successfully achieved with native tissue using a vaginal approach with uterosacral ligament (USL) suspension. However, severe complications have been described, mainly related to ureteral injury.

Methods

A 57-year-old woman with symptomatic stage 2 vaginal vault prolapse underwent transvaginal USL suspension according to the described technique.

Results

Surgical procedure was successfully achieved without complications. Final examination revealed excellent apical support and preservation of vaginal length. However, ureteral damage represents the major pitfall of USL suspension. This step-by-step video tutorial may represent an important tool to improve surgical know how and minimize the risk of ureteral injury.

Conclusion

Transvaginal USL suspension provides an effective technique for apical support without the use of prosthetic materials. Intimate understanding of pelvic anatomy, direct visualization of ureter, and proper suture positioning are the key points to minimize the risk of complications.

     

Extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation: a meta-analysis

Background

We reviewed the available literature on patients undergoing lung transplantation supported by cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO).

Methods

A systematic literature search was performed in three databases, in accordance with the PRISMA guidelines. Meta-analyses were used to compare the outcomes of ECMO and CPB procedures.

Results

Seven observational studies met the inclusion criteria incorporating 785 patients. ECMO support showed lower rate of primary graft dysfunction, bleeding, renal failure requiring dialysis, tracheostomy, intraoperative transfusions, intubation time, and hospital stay. Total support time was greater for the ECMO-supported group. No difference was reported between operative and ischemic time.

Conclusions

The present study indicates that the intraoperative use of ECMO is associated with increased efficacy and safety, regarding short-term outcomes, compared to CPB. Well-designed, randomized studies, comparing ECMO to CPB, are necessary to assess their clinical outcomes further.

     

Implementation and evaluation of structured nephrology morbidity and mortality conferences: a quality education report

Background

Morbidity and Mortality Conferences (M&MCs) have for generations been part of the education of physicians, yet their effectiveness remains questionable. The Ottawa M&M Model (OM3) was developed to provide a structured approach to M&MCs in order to maximize the quality improvement impact of such rounds.

Study design

We conducted a retrospective assessment of the impact of implementing nephrology-specific M&MCs using the OM3.

Setting and participants

All physicians, residents and fellows from the division of nephrology at a large academic medical center were invited to participate.

Quality improvement plan

Structured M&MCs were implemented to identify preventable errors and generate actions to improve quality of care and patient safety.

Outcomes

Number and nature of cases reviewed, number and nature of recommendations generated through identification of preventable health system and/or cognitive factors.

Measurements

Morbidity and/or mortality in each case were identified. A determination of the underlying factors and preventability of these events was made. A qualitative review of resulting recommendations was performed.

Results

Over the course of sixteen 1-h long conferences, 52 cases were presented. For all cases presented, discussion, action items and information dissemination followed the OM3. As a result of the M&MCs, 29 recommendations (emanating from 27 cases) lead to improve care delivery.

Limitations

Limitations of this study include its retrospective nature and single-center design.

Conclusions

The implementation of regularly scheduled M&MCs at an academic nephrology program, using a structured model, identified preventable health-systems issues and cognitive errors. Approximately one-half of the cases reviewed generated actions for health care delivery improvement.

     

Cost-Effectiveness in Global Surgery: Pearls,Pitfalls, and a Checklist

Introduction

Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.

Methods

The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.

Results

Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.

Conclusion

Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.

     

„Lauterkeit“ im Gesundheitswesen

Background

This article describes the introduction of the law to combat corruption in the healthcare system.

Objective

The effects of the introduced penal regulations on the delivery of medical services is critically scrutinized and the associated procedures as well as indications for the course of action are presented.

Results

Knowledge of the relevant regulations and types of procedure is decisive for the penal, social legislative and professional conduct risk minimization.

     

Entzündlich-rheumatische Erkrankungen

Background

Inflammatory rheumatic diseases can lead to cartilage changes.

Methods

PubMed literature search

Results

The rheumatoid arthritis can produce degrading enzymes and cause cartilage damage; longitudinal studies do not exist.

Conclusion

There are no high level studies. The expert opinion is that infammatory rheumatic diseases can lead to osteoarthritis of the knee.