Endoscopic haemostasis of staple-line haemorrhage following colorectal resection

Objective  Bleeding from stapled colonic stapled anastomoses is rare, but occasionally may be severe enough to require re-operation, with associated morbidity. Endoscopic therapy is a potential alternative.
Method  We examined a large 15-year prospective series of patients who had undergone colorectal resection with stapled anastomosis. We reviewed the management of cases where severe postoperative rectal bleeding had occurred.
Results  In six of 777 (0.8%) patients, bleeding occurred that was severe enough to require intervention. In the first three cases, conventional re-operation was performed. In the latter three cases, endoscopic therapy (adrenaline injection, diathermy or endoscopic clipping) was used to control the bleeding. No complications occurred as a result of endoscopic therapy, either patient or anastomosis related.
Conclusion  Endoscopic management using standard endoscopic techniques appears safe and effective for haemostasis in colorectal stapled anastomotic bleeding. Endoscopic therapy should probably be attempted before re-operation is considered.     

Relationship of preadmission variables and first- and second-year course performance to performance on the National Board of Osteopathic Medical Examiners' COMLEX-USA Level 1 examination

The purpose of this study was to examine the relationship of performance on the Comprehensive Osteopathic Medical Licensing Examination (COMLEX-USA) Level 1 licensing examination to (1) academic performance during the first 2 years of the curriculum, and (2) preadmission grade point averages (GPAs) and Medical College Admission Test (MCAT) scores for one osteopathic medical school with the unique mission of providing osteopathic family physicians for West Virginia and rural Appalachia. Simple correlations were calculated for the 63 students at West Virginia School of Osteopathic Medicine who completed all requirements of the first 2 years of the curriculum in May 1998 and were first eligible for board exams in June 1998. These included 26 (41.3%) female students and 5 (7.9%) minority students. Students who had failed a year and/or a course but subsequently successfully completed the first 2 years of the curriculum in May 1998 were included in this study. Every student who qualified to take the June 1998 administration of COMLEX-USA Level 1 did so at that time. For the 55 academic or preadmissions variables of interest, correlation coefficients with COMLEX-USA Level 1 scores and significance levels were calculated using SPSS Base 9.0. The correlation of COMLEX-USA Level 1 performance with GPA for Phase I was 0.64; with GPA for Phase II, 0.67; and total GPA for the first 2 years, 0.70. Grades in most individual courses also correlated significantly with COMLEX-USA Level 1 performance. Given the special focus of this curriculum on the needs of the Appalachian region and use of clinical performance measures or participation measures in calculating academic GPAs, these correlations show a remarkable degree of agreement between these two sets of performance measures. Further research is needed to see if similar relationships exist for osteopathic medical schools with other missions and with other curriculum structures. Preadmissions GPAs and MCATs did not significantly relate to performance on COMLEX-USA Level 1.     

Endoscopic Gastrostomy Button With Double-Lasso U-Stitch in Children

Methods:This is a retrospective review of a single center''s experience of 24 consecutively performed primary gastrostomy button placements in infants and children aged 3 weeks to 20 years, from October 2012 through October 2014.Results:The procedure was generally well tolerated, with no intraoperative complications. No conversions to laparoscopic or open procedures were necessary. There were no early tube dislodgements and no postoperative complications within the first 4 weeks.Conclusion:The endoscopic primary gastrostomy button placement with a transcutaneous lasso U-stitch is a safe, fast, elegant, and cost-effective alternative to a standard percutaneous endoscopic gastrostomy placement.     

经尿道内镜术治疗前列腺术后膀胱出口梗阻

目的：探讨经尿道内镜技术治疗前列腺术后膀胱出口梗阻的疗效。方法：采用经尿道内镜术治疗35例前列腺术后（经耻骨上前列腺除30例，经尿道电切5例）排出困难，经尿道膀胱造影或尿道膀胱镜检查证实为前列腺尿道部或膀胱颈狭窄的病人。结果：35例均获成功，拔除尿管后均排悄通畅，无尿液残余，少部分病人有尿频，但经对症处理很快改善。结论：经尿道内镜术处理前列腺术后膀胱出口梗阻安全、可靠，是首选的治疗方法。     

Technique and results of vascular endoscopy in arterial and venous reconstructions

In an effort to maximize results, vascular endoscopy was used in our institution to monitor arterial and venous reconstructions. Since 1982, angioscopy was applied as a control method in 182 venous thrombectomies to treat iliofemoral thrombosis and 114 aortoiliac thromboendarterectomies. Of the cases with venous thrombectomy reviewed, 50% were incomplete by endoscopic evidence; of these, in 80% the remaining clots could be partly or completely removed. Additionally, in six patients a venous spur was found. Of 114 attempted aortoiliac thromboendarterectomies, only 91 could be completed. In the remainder, endoscopic evidence of persistent intimal flaps forced us to bypass the affected segments. With further miniaturization of the angioscopes, the method was also applied to check vessel repair on small-caliber arteries. In an initial study with 220 femorodistal bypasses we were unable to find a statistically significant difference of primary patency in grafts that were endoscopically controlled or not. In the learning phase with the in situ technique, we identified competent valve remnants in 40%, but this rate could be reduced to 12.7% with growing experience in valvulotomy. We conclude from our data that angioscopy is very helpful in assessing the morphological integrity of aortoiliac thromboendarterectomies and venous thrombectomies. The actual value in infrainguinal arterial reconstructions still remains to be proven.     

The creation of a peritoneal defect in transanal endoscopic microsurgery does not increase complications

Introduction  During Transanal Endoscopic Microsurgical (TEMS) full-thickness excision of a rectal lesion above the peritoneal reflection, entrance to the peritoneal cavity is inevitable. This has been regarded as a complication that requires conversion to an open procedure. We describe our experience of full thickness intraperitoneal excision of rectal lesions where the peritoneal defect was sutured endoscopically.
Method  Data were collected prospectively on 15 patients in whom a peritoneal defect was created intraoperatively during TEMS excision of a rectal lesion. When a defect was recognized, it was closed by endoscopic suture. If there was any doubt regarding security of the closure, a defunctioning loop stoma was fashioned.
Results  Between November 1998 and January 2008, a total of 257 patients underwent TEMS during which a peritoneal defect was created in 15 patients. Six patients had a defunctioning stoma formed at the time of TEMS. No patient was defunctioned postoperatively and there were no deaths. The mean hospital stay was 8 days (range 3 to 19 days). A contrast enema showed sub-clinical leaks in two patients for which no treatment was required. No patient developed pelvic or peritoneal sepsis, but one patient had to return to theatre for postoperative bleeding when a single bleeding vessel was coagulated.
Conclusion  Full thickness excision of lesions in the intraperitoneal rectum with endoscopic suture of the defect is a safe procedure. Lesions in the upper rectum should not be excluded from TEMS excision because of the chance of peritoneal breach.     

Selective upper endoscopy for foreign body ingestion in children: an evaluation of management protocol after 282 cases

Purpose

Foreign body ingestion is a common problem in both children and adults. This study aims to evaluate a management protocol where endoscopic examination was only selectively used after routine direct laryngoscopy to minimize patient discomfort and the need for general anesthesia in children.

Method

A management protocol for foreign body ingestion based on symptoms was introduced in 1998 and records of children admitted to a university-affiliated hospital between January 1999 and October 2005 with suspected foreign body ingestion were evaluated. Symptoms, radiologic and endoscopic findings, and outcome were reviewed.

Results

A total of 282 patients were admitted. The mean age of patients was 5.75 years (range, 9 months to 17 years). There were 167 boys and 115 girls. Based on our protocol, 84 (29.8%) patients required an upper endoscopy. Fish bones were most commonly involved (68.8%). Foreign bodies, which were either removed or dislodged, were found during upper endoscopy in only 25 (8.8%) patients overall. All patients had an uneventful outcome. No complications or mortalities were encountered. There were no readmissions for those who did not undergo endoscopic examination.

Conclusion

It is safe to selectively perform upper endoscopy depending on symptoms when managing children with foreign body ingestion.     

Studentische Ausbildung in Katastrophenmedizin

Background

This article reports on the implementation and evaluation of a student course in disaster medicine at Regensburg University Medical School according to a model curriculum issued by German authorities.

Materials and Methods

The model curriculum had been adapted to local capabilities. A total of 24 students participated in the course which featured 13 lectures and 3 practical training sessions involving 1 decontamination and 2 map exercises on mass casualty incidents. During map exercises the participants had to manage scenarios involving 10 and 25 patients, respectively, in real time.

Results

The course achieved very good ratings during evaluation and students requested more practical training sessions in future courses. In the statistical evaluation of the student self-assessment a significant learning progress could be shown. Practical training achieved better ratings than theoretical lectures.

Conclusion

The model curriculum for a student course in disaster medicine could be implemented for the first time. The student’s competence in dealing with disasters increased during the course. From this experience conclusions for the improvement of the model curriculum can be drawn.     

Impact of the problem-based learning curriculum on the learning styles and strategies of medical students at the University of Transkei.

OBJECTIVES: This is a longitudinal cohort study of the learning styles and strategies of medical students in a problem-based, community-based curriculum as they progressed through the medical course. The purpose was to monitor and evaluate whether the programme was fulfilling the objective of producing self-directed and lifelong learners. METHODS: The short version of the Lancaster Inventory of Learning Styles was administered to the students on admission and thereafter on a yearly basis through the first 4 years of the medical course. Data were fed onto a database and subsequently analysed using a commercially available statistical package. RESULTS: 140 students (falling to 106 by year 4) were interviewed and followed up through the study period. Of the students 75% were black and 25% were of Asian descent. On admission the students had high scores for individual achievement motivation, and for meaningful learning. They had moderate scores for reproducing learning, comprehension learning, operation learning and versatile learning. They had low scores for learning pathologies, especially globetrotting and improvidence. There was no sexual difference in learning styles. Asian students had significantly higher scores for meaningful learning and for versatile learning. The effect of the problem-based curriculum was to reduce the score for individual achievement, decrease the score for fear of examinations, increase the score for operation learning, increase the score for versatile learning, increase the score for syllabus boundness, and decrease the scores for learning pathologies, especially for improvidence and globetrotting. By year 4, there was similarity in the learning styles of black and Asian students. CONCLUSION: The problem-based curriculum had a positive effect on the learning styles of the students, especially the black students.     

Endoscopic management of recurrent primary bile duct stones

Background: The management of recurrent choledocholithiasis today remains as challenging as in the pre‐endoscopic era. Between 2 and 7% of affected patients have historically required surgical intervention for the treatment of recurrent or retained choledocholithiasis and of these, as many as 24% develop biliary complications. To avoid surgery, repeated endoscopic management of the problem has been suggested. In this study, we evaluate our policy of repeated endoscopic management of recurrent primary bile duct stones. Methods: This study examined a cohort of nine patients identified from a prospective database with recurrent choledocholithiasis. Demographic, clinical and investigative details were recorded and data were analysed. Complications were determined from a review of the patient’s file. Results: There were nine patients and 66 procedures were carried out. Mean age at time of first endoscopy was 70.1 years (36–91 years). Three patients were of male sex (33.3%). The mean number of endoscopies carried out per patient was 7.3 (3‐13). Failure to completely clear the duct occurred in 36.4% of all endoscopies. There were no periprocedural complications. Conclusion: Repeated endoscopic stone extraction by endoscopic retrograde cholangiopancreatography when required is a safe policy. However, this technique will only provide temporary relief from primary duct stones and repeated endoscopic treatment, again safe, will be required.     

Dual interventional approach of endoscopic reboring in completely stenosed rectal anastomosis using radiology guidance: a novel technique

Objective  Rectal stricture/stenosis is a well-recognized complication following anterior resection. Completely stenosed rectal anastomoses have been conventionally treated conservatively with permanent stoma. The surgical alternatives are either a redo low resection with its accompanying hazards or formation of a permanent colostomy. We describe a simple method of treating anastomotic stenoses using a novel technique in patients with a defunctioned bowel.
Method  Three patients with complete stenosis of a rectal anastomosis following anterior resection underwent this novel technique with informed consent. A stenosis with no identifiable lumen was diagnosed at the time of examination under anaesthetic (EUA) or by contrast enema. Using a novel technique of combined endoscopic and radiology guidance, the anastomotic stenosis was rebored and subsequently dilated to restore bowel continuity.
Results  There were no complications observed following this procedure. Two of the three patients needed repeat endoscopic dilatation. All patients had restoration of the lumen in the anastomosis and subsequently underwent closure of ileostomy and made an uneventful recovery.
Conclusion  Combined endoscopic dilatation under radiological guidance is a novel technique and appears to be a simple, safe, effective and inexpensive method for treating rectal anastomotic stenoses.     

The Safety and Efficacy of Salicylic Acid Chemical Peels in Darker Racial-ethnic Groups

Background. There is a dearth of published data regarding chemical peels in darker racial-ethnic groups.
Objective. The purpose of the present investigation was to assess the clinical efficacy and safety of a new superficial salicylic acid peel in individuals of skin types V and VI.
Methods. Twenty-five patients were included in this pilot investigation. Nine had acne vulgaris, 5 had post-inflammatory hyperpigmentation, 6 had melasma, and 5 had rough, oily skin with enlarged pores. The patients were pre-treated for 2 weeks with hydroquinone 4% prior to undergoing a series of five salicylic acid chemical peels. The concentrations of salicylic acid were 20% and 30%. The peels were performed at 2 week intervals.
Results. Moderate to significant improvement was observed in 88% of the patients. Minimal to mild side effects occurred in 16%.
Conclusion. The results of this study suggest that superficial salicylic acid peels are both safe and efficacious for treatment of acne vulgaris, oily skin, textural changes, melasma, and post-inflammatory hyperpigmentation in patients with skin types V and VI.     

护理专业学生学习风格与学习成绩的相关性研究

目的 分析护理专业学生学习风格与学习成绩的关系,研究相应的教学策略.方法 采用Kolb学习风格量表对283名护理专业学生进行学习风格调查,分析其学习风格与学生成绩的相关性.结果 不同学习风格的护理专业学生在学习成绩上存在差异性(均P＜0.05);学习倾向偏好与学习成绩存在显著相关性(P＜0.05,P＜0.01).结论学习风格影响学习效果.要提高护理专业学生的学习质量,应加强反思观察与抽象概念的训练,使学生学会学习;同时应变被动实践为主动实践,挖掘学生的创新能力.     

Peroral endoscopic reduction of dilated gastrojejunal anastomosis after Roux-en-Y gastric bypass: a possible new option for patients with weight regain

Background Roux-en-Y gastric bypass (RYGB) is an effective treatment for severe obesity. However, many patients regain weight over time. The mechanisms for this are unclear, and several factors may contribute, including dilation of the gastrojejunal anastomosis. This study aimed to assess the feasibility of endoscopic gastrojejunal anastomotic tightening and to determine the effect of tightening on body weight. Methods Eight patients with significant weight regain and dilated gastrojejunal anastomosis after RYGB were included in this pilot study. Sutures were placed endoscopically at the rim of the anastomosis. When tightened, the sutures formed tissue placations, reducing the size of the anastomotic aperture. Results The average preprocedure body mass index (BMI) was 40.5, and the patients had regained a mean of 24 kg from their post-RYGB nadir. The average pouch length was 5.7 cm, and the average anastomotic diameter was 25 mm. The average postreduction diameter was 10.0 mm (68% reduction). Six of the eight patients showed weight loss (mean, 10 kg) at 4 months. Repeat procedures were performed for three patients who had lost 4, 5, and 9 kg, respectively with the initial procedure. After the second anastomotic reduction, the final diameters were, respectively, 14, 5, and 5 mm. The first patient did not have further weight loss. The remaining two patients showed a total weight loss of 19 and 20 kg, respectively, at 5 months. All 11 reductions were accomplished without significant complication. The average postreduction BMI was 37.7, and the percentage of excess weight loss was 23.4%. Conclusion Peroral endoscopic suturing to tighten dilated gastrojejunal anastomoses appears technically feasible and safe. This procedure is associated with variable but significant weight loss, and preliminary results suggest that it may offer a new treatment option for postbypass weight regain in selected patients.     

LASER TREATMENT OF PHARYNGEAL POUCH

The symptoms of pharyngeal pouch become more troublesome, eventually requiring surgical treatment. Excision of the pouch and cricopharyngeal myotomy through a neck incision was the operation of choice until Dohlman described endoscopic diathermy operative treatment 30 years ago.' The diathermy technique has been largely superseded by endoscopic microsurgical division of the cricopharyngeus muscle in the party wall using carbon dioxide laser. This operation is now established as a precise, accurate and safe procedure providing reliable relief of symptoms with minimal risk to the patient. Fifteen patients treated by the microsurgical laser procedure in the past 5 years am reported.     

Fear of missing a lesion: use of simulated breast models to decrease student anxiety when learning clinical breast examinations

BACKGROUND: Medical students experience a considerable amount of discomfort during their training. The purpose of the current study was to identify sources of student anxiety when learning clinical breast examinations (CBEs) and to evaluate the effects of simulated breast models on student comfort. METHODS: Simulated breast models were introduced into the curriculum for 175 second-year medical students. Using surveys, students identified sources of anxiety and rated their comfort levels when learning CBE skills. RESULTS: "Fear of missing a lesion" and the "Intimate/personal nature of the exam" accounted for 73.8% of student anxiety when learning CBEs. In addition, there were significant improvements (P < .05) in student comfort levels when using simulated breast models to learn CBE skills. CONCLUSIONS: We have identified 2 of the top causes of anxiety for second-year medical students learning CBE. In addition, we found simulated breast models to be effective in increasing student comfort levels when learning CBEs.     

Acquiring surgical skills: the history of surgical teaching at the University of Sydney 1883–2014

There have been at least 10 major revisions of the medical curriculum since the inauguration of the Faculty of Medicine at the University of Sydney in 1883. This study traced the evolution of the teaching of surgery at our institution by examination of the set curriculum of each period; the expectations of student knowledge in the final examination as well as examining some of the insights provided by past students of their surgical experience through their writings. In the early years, medical graduates were qualified to perform operative surgery without any further training, whereas the modern postgraduate medical curriculum provides students with the basis for further surgical training.     

Surgical intern survival skills curriculum as an intern: does it help?

Background

The transition from medical student to surgical intern is fraught with anxiety. We implemented a surgical intern survival skills curriculum to alleviate this through a series of lectures and interactive sessions. The purpose of this pilot study was to evaluate its effectiveness.

Methods

This was a prospective observational pilot study of our surgical intern survival skills curriculum, the components of which included professionalism, medical documentation, pharmacy highlights, radiographic interpretations, nutrition, and mock clinical pages. The participants completed pre-course and post-course surveys to assess their confidence levels in the elements addressed using a 5-point Likert scale (1 = unsatisfactory, 5 = excellent). A P value of less than .05 was considered significant.

Results

In 2009, 8 interns participated in the surgical intern survival skills curriculum. Fifty percent were female and their mean age was 27.5 ± 1.5 years. Of 33 elements assessed, interns rated themselves as more confident in 27 upon completion of the course.

Conclusions

The implementation of a surgical intern survival skills curriculum significantly improved the confidence levels of general surgery interns and seemed to ease the transition from medical student to surgical intern.     

Transgastric access By balloon overtube for intraperitoneal surgery

The final frontier in endoscopy is the peritoneal cavity which was recently reached through natural orifice transluminal endoscopic surgery (NOTES). Endoscopic perforation caused by NOTES has been the major challenge for this procedure because of the risk of peritonitis and consequent complications. We describe in a dog model the use of an overtube system, one of them with a balloon, to access the peritoneal cavity by NOTES. It permits direct access to the peritoneal cavity from the mouth and also allows the performance of a controlled perforation and provides conditions for a safe closure of the gastric wall.     

Evaluating the impact of a curriculum intervention using an assessment rubric for communication skill development of osteopathy students

ObjectiveThis paper investigates the impact of a spiral curriculum intervention using a validated assessment rubric for communication skill development of undergraduate osteopathy students.MethodOver a three-year period, students from three cohorts were exposed to zero, one or two semesters of a newly integrated and scaffolded communication curriculum. Using a checklist rubric to collect mean scores and then undertaking comparisons through Pearson chi square analysis, the impact of the curriculum intervention on communication skill development was explored.ResultsCohorts who received zero or two full semesters of communication curriculum performed better (x = 6.34, x = 10.51 respectively) than the cohort who received one (x = 6.03).ConclusionDespite using an explicit assessment rubric, insufficiently contextualised and integrated curriculum appears to disrupt student learning, whilst a spiralled, scaffolded curriculum delivered at an appropriate level in combination with explicit assessment rubrics work well together to support deeper learning and development.Implications for practice∙An insufficiently contextualised and integrated curriculum combined with the frequency of content being re-visited (spiral curriculum) can disrupt the students learning experience.∙Using a spiralled and scaffolded curriculum significantly improves the development of communication skills.∙For deeper learning to occur students require a combination of both explicit curriculum and accompanying assessment rubrics.