General surgery in adult hemophiliacs

From 1976 to 1984, 23 operations were performed on 22 patients with hemophilia (18 patients with factor VIII and four with factor IX deficiency). Elective procedures included resection of abdominal aortic aneurysm, liver transplantation, vagotomy/pyloroplasty, insertion of Mousseau-Barbin tube, colectomy, cholecystectomy, inguinal herniorrhaphy (four patients), colonoscopy/polypectomy, mediastinoscopy, arteriovenous fistula for dialysis, anal fistulectomy, and miscellaneous skin and soft-tissue procedures (five patients). Emergency operations were appendectomy (two patients), repair of bleeding liver biopsy site, and repair of an incarcerated inguinal hernia. There were two deaths (9%) within 30 days of operation, neither directly caused by the coagulopathy. Four patients had bleeding after surgery, which was treated with additional cryoprecipitate or factor concentrate. There were no nonhemorrhagic complications. Before operation, appropriate replacement therapy with factor VIII concentrate, cryoprecipitate, or fresh-frozen plasma was provided. Coagulation factor levels were measured before operation and monitored daily after operation. Generally, factor levels were raised to at least 1.0 U/ml and maintained at greater than 0.5 U/ml for 7 to 14 days after operation. However, when patients were treated with fresh-frozen plasma, plasma exchange was performed and factor levels of approximately 0.35 U/ml were achieved before surgery. We conclude that operations in patients with hemophilia can be accomplished safely with careful monitoring of coagulation factor levels and appropriate replacement therapy.     

General surgery career resource

General surgery residency training can lead to a rewarding career in general surgery and serve as the foundation for careers in several surgical subspecialties. It offers broad-based training with exposure to the cognitive and technical aspects of several surgical specialties and prepares graduating residents for a wide range of career paths. This career development resource discusses the training aspects of general surgery.     

General surgery resident experience with anorectal surgery

BackgroundPrevious studies have suggested that general surgery residents graduate with suboptimal anorectal experience. However, competence in anorectal procedures is an important part of general surgery training.MethodsACGME general surgery resident case logs from 1999 to 2017 were reviewed. Mean number of anorectal procedures were evaluated, comparing Period 1 (1999–2008) and Period 2 (2009–2017).ResultsBetween 1999 and 2017, the mean number of all anorectal procedures performed by each general surgery resident has increased from 25.9 to 32.4 (by 25%). Between Period 1 and 2, mean numbers of total anorectal procedures, abscess drainage, fistula repair, hemorrhoidectomy, prolapse repair, other anorectal procedures all increased (p ≤ 0.01). Mean numbers of sphincterotomy/sphincteroplasty and other procedures for fecal incontinence significantly decreased (p ≤ 0.01).ConclusionsGeneral surgery residents have gained more experience in some anorectal procedures over time. The required number of procedures to establish competence is not well defined and should be formally evaluated.