Adding an endovascular aortic surgery program to a rural regional medical centre

Background

Abdominal aortic aneurysms requiring surgical intervention are generally treated by endovascular means. Such procedures are not always offered in rural hospitals, possibly leaving patients underserved. We reviewed our experience initiating an endoaortic surgery program.

Methods

A surgeon in a rural centre was credentialed to perform endovascular aortic aneurysm repair through collaboration with a university centre and was proctored locally for the first 5 abdominal aneurysm repairs. Web-based image storage was used to review complex cases as part of an ongoing partnership. Referred patients were screened for multiple aneurysms and underwent long-term monitoring.

Results

In all, 160 patients were evaluated for 176 aortic pathologies. Twenty-five patients (17 men) aged 55–89 years underwent 26 endovascular abdominal (n = 23) or thoracic (n = 3) aortic procedures. Emergent endovascular procedures were not performed. There were no operative deaths, requirements for dialysis or conversions to open repair. Two endoleaks required early reintervention. The median length of stay in hospital for endovascular procedures was 2.5 days. Chronic endoleaks were observed in 7 patients. An additional 8 patients underwent open abdominal aneurysm repair locally and 15 patients were referred to the university program.

Conclusion

Creation of an endovascular aortic surgery program in a rural hospital is feasible through collaboration with a high-volume centre. Patient safety is enhanced by obtaining second opinions using web-based image review. Most interventions are for abdominal aortic aneurysms, but planning for a comprehensive aortic clinic is preferable.     

Comparative analysis of successful and unsuccessful candidates for the pediatric surgical matching program.

Only one third of the applicants for training in pediatric surgery obtain a position through the pediatric surgery matching program. In order to identify factors that contribute to a successful outcome, we conducted a retrospective survey of all participants in the matching process for positions during the years 1983 to 1991. This survey was designed to identify characteristics associated with success in the match through comparison of successful and unsuccessful applicants. Significant factors associated with a successful match included: a greater incidence of residency-supported research (P = .012) with a greater number of publications (P = .003) and national presentations (P = .014), specifically at the annual meetings of the American Pediatric Surgical Association (P = .05) and the American Academy of Pediatrics (P = .05). In addition, successful candidates had more contact with (P = .004) and letters of recommendation from (P = .015) well-known pediatric surgeons involved in the general surgical residency program. This information should be invaluable to those counseling medical students and residents interested in a career in pediatric surgery.     

Parathyroidectomy after successful kidney transplantation: a single centre study.

BACKGROUND: Successful kidney transplantation is believed to cure secondary hyperparathyroidism, but persistent disease has emerged in a significant number of allograft recipients. A parathyroidectomy is ultimately required in some of these patients. To gain insight into the incidence, risk factors and consequences of parathyroidectomy in patients with a functioning renal graft, we performed a retrospective case-controlled study. METHODS: Charts of 1743 recipients of a kidney allograft, transplanted between 1989 and 2004, were reviewed. Patients with a functioning graft subjected to parathyroidectomy were identified. Their charts were checked for various demographic, clinical and biochemical variables. The data were compared with those obtained from patients transplanted in the same period, but not subjected to parathyroidectomy (controls). RESULTS: Persistent hyperparathyroidism in patients with a functioning graft requiring parathyroidectomy developed in 90 patients, corresponding to an overall parathyroidectomy rate of 8.89 per 1000 person-years at risk. Female gender (OR 1.79, P < 0.05) and higher pre-transplant serum concentrations of PTH (OR per 1 ng/l increase, 1.003, P < 0.0001) and calcium (OR per 1 mg/dl increase, 2.58, P < 0.0001) were identified as independent predictors of post-transplant parathyroidectomy. A significant increase of the serum creatinine was observed after parathyroidectomy (1.91 +/- 0.72 vs 1.76 +/- 0.63 mg/dl, P < 0.01). Graft survival, however, was similar in cases and controls. CONCLUSION: Persistent hyperparathyroidism requiring parathyroidectomy after successful renal transplantation is a common clinical problem. Female patients with a high pre-transplant serum level of PTH and calcium are especially at risk. Although graft function deteriorates shortly after parathyroidectomy, graft survival, overall, is not different from controls.     

Launching a successful robotic surgery program

Robotic-assisted laparoscopic prostatectomy is rapidly becoming the most commonly performed surgical approach to treat clinically localized prostate cancer. The establishment of a robotic surgery program at any institution requires a structured plan and certain key elements to be in place to allow successful development. At least five essential phases are necessary for successful implementation of a robotics program. A thorough initial design and implementation lead to the execution of clinical services that meet previously established goals. Once the execution phase is established, the next step is to focus on maintenance and growth to maximize the benefits of the program. In this paper, we discuss the necessary phases for creating a successful robotic program, paying special attention to the aspects that allowed our facility to create a profitable robotic-assisted laparoscopic prostatectomy program in year 1.     

Minimally invasive surgical practice: a survey of general surgeons in Ontario.

INTRODUCTION: With the rapidly evolving techniques for minimally invasive surgery (MIS), general surgeons are challenged to incorporate advanced procedures into their practices. We therefore carried out a study to assess the state of MIS practice in Ontario. METHODS: A questionnaire was mailed to 390 general surgeons in Ontario. It addressed the surgeon's practice demographics, performance of both basic and advanced MIS procedures, the factors influencing this practice and the means of obtaining MIS training. RESULTS: Of the 390 general surgeons surveyed, 309 (79%) responded. Thirty-six of these were retired and were excluded from the analysis, leaving 273 available for study. The average age in the study group was 49.7 years; 247 (90%) were men. Of 272 who responded to the question, 116 (43%) had subspecialty training. The average surgeon's operating room (OR) time was 1.5 d/wk and the average waiting time for elective procedures was 4 weeks. We found that 257 (94%) respondents performed basic laparoscopic procedures, and 164 (60%) performed appendectomy; 135 (49%) performed at least 1 advanced laparoscopic procedure in their practice, although only 30 (22%) of these performed inguinal hernia repair. Using a Likert scale, we found that the most important factors influencing the incorporation of advanced laparoscopic procedures into surgical practice were a lack of OR time (median 4), lack of OR financial resources (median 4) and lack of training opportunities (median 4). Of surgeons responding to questions, 161 (64%) of 251 felt that the present medical environment did not allow them to meet standard-of-care requirements; they felt that it was the responsibility of academic surgical departments (214 [80%] of 268), the Canadian Association of General Surgeons (177 [68%] of 262) and the Ontario Association of General Surgeons (141 [53%] of 264) to provide continuing medical education courses for MIS training. CONCLUSION: The ability of practising general surgeons to incorporate advanced MIS procedures into their surgical practice remains a complex issue.     

Secondary intervention following endovascular repair of abdominal aortic aneurysm: a single centre experience.

AIMS: We aim from a review of our early and late experience of secondary intervention for technical failures, to examine and describe the impact of endovascular and open interventions. METHODS: 108 Abdominal Aortic Aneurysms (AAAs) repaired endoluminally between 1995-2001 were analysed. In our early experience, during 1995/96 home made pre-expanded polytetrafluoroethylene grafts fixed with Palmaz stents were used (n = 26). In our later experience, 1997/2001 Talent (n = 70) or Zenith endografts (n = 12) were used. All cases underwent spiral CT at 5 days and 6 monthly intervals post-op. Angiography was performed when further intervention was intended. All technical failures requiring intervention or not were studied. RESULTS: There were 28 (26%) technical failures identified of which 14 of 26 (54%) occurred in our early experience, and 14 of 86 (16%) occurred in our later experience (p < 0.05). Eleven in all required open conversion at the time of endovascular repair. Our study cohort were the remaining 17 cases requiring secondary intervention, seven were from our early experience and 10 from our later experience. There were 12 endoleaks, including two as a result of graft migration, two graft occlusions, two graft distortions and one graft infection. Overall 10 (66%) technical failures were treated by endoluminal repair and seven (34%) by open methods. However, in our later experience significantly more endoluminal techniques (80%) were used (p < 0.05). CONCLUSIONS: Technical failure rates were significantly higher in our earlier experience. Open repair, which was a feature of our early experience, has been avoided over the final 3 years. Instead, endoluminal techniques were used without further morbidity or mortality. Aneurysm rupture has not so far been experienced in this experience.     

Staged endovascular stent-grafting and surgical treatment of a secondary aortoduodenal fistula.

Secondary aortoenteric fistula is a dramatic, rather infrequent late complication occurring mostly after abdominal aortic surgery. Currently, graft excision and in situ bypass is considered the treatment of choice, but it is associated with significant mortality and morbidity. Herein, we describe the case of a secondary aortoduodenal fistula treated by staged endovascular stent-grafting and surgical closure of the fistula. Forty days after stent-grafting, Tc-99m-HMPAO labelled leukocyte scanning failed to identify leukocyte infiltration of the graft and there were no clinical signs of infection. At 8-month follow up, the patient was asymptomatic.     

Preliminary assessment of a scientific curriculum in a surgical residency program.

A structured, basic science curriculum was instituted for surgical residents of the University of Connecticut (Farmington) Integrated Residency Program during the 1990-1991 academic year in concordance with American Board of Surgery guidelines. The impact of the new program was measured by comparing performance on monthly basic science examinations, the in-training examination, and "mock" oral examinations for the 1990-1991 academic year with that of the preceding academic year. While monthly examination scores improved for the entire group of residents (67.7 vs 64.6), in-training and oral examination scores did not change significantly. Categorical residents generally demonstrated superior performance and greater improvement than did preliminary residents. Data analysis suggested that the new curriculum was an effective educational device and that university-designed monthly examinations were valid testing instruments, but there was an apparent incongruity between the goals of the curriculum and the American Board of Surgery In-Training Examination.     

Percutaneous injuries in a high-volume podiatric surgical residency program.

Percutaneous injuries (i.e., needlesticks) are a possible occupational hazard to all residents performing invasive procedures. Transmission of blood-borne pathogens has become a potential risk in these injuries. As such, the purpose of this investigation was to assess the frequency and circumstances involving percutaneous injuries in the podiatric surgical resident. A survey of 20 present residents from July 1991 to July 1999 was conducted to assess percutaneous injuries. These residents participated in 19,505 surgical cases in this timeframe; 16,185 were podiatric cases and 3,347 were nonpodiatric. Using a two-part questionnaire to assess the circumstances surrounding any percutaneous injury, 80% of the residents reported at least one percutaneous injury during their training. A total of 33 were injuries reported for the 19,505 cases. The incidence of injury per surgical case was 0.17% overall, and 0.14% for foot and ankle cases. Analysis of the data showed a median = 2, mode = 2, and a mean = 1.63 injuries per resident with a range of 0-5. When analyzing the circumstances involving the injuries, most injuries were self-inflicted (66.7%), occurred during wound closure (72.7%), and were caused by a nonhollow bore needle or instrument (81.8%). Also, no correlation could be made to the time of day during which the procedure was performed, the year of residency training, or the number of cases that the resident performed that day before the injury occurred. Interestingly, over 67% of the injuries occurred to the resident's left hand. Although 97% of the injuries were reported to the employee health officer, the patient and resident were screened for HIV and hepatitis B or C in only 78.8% of the cases. In those tested, no resident was exposed to HIV or hepatitis B or C.     

Renal aneurysms: surgical vs. endovascular treatment

Renal artery aneurysms (RAA) are rare (general population incidence is 0.09%). At this time, the appropriateness of the type of intervention ? surgical or endovascular ? is based on single center experiences rather than large randomized trials. Endovascular therapy offers less morbidity but surgery has excellent long-term results. In reality, the choice of the treatment relies on the operative risk. A patient with a RAA and good surgical risk should be offered open surgery. If the patient is deemed to be at high risk from surgery then the choice of the type of endovascular treatment (stent grafting, coil/glue embolization, multilayer stenting) should be based on the location and shape of the RAA. RAA should be treated by surgeons/interventionalists who have demonstrated expertise in renal artery procedures.     

Development of a successful non-heart-beating organ donation program

To help alleviate the organ shortage, transplant centers are using organs from expanded-criteria donors, who were considered unsuitable just a few years ago, such as non-heart-beating donors. In 1998, we made a concerted effort to increase the number of non-heart-beating donors recovered by our organ procurement organization. In this paper, we discuss the steps in establishing this program, including transplant center support, estimating the number of potential non-heart-beating donors, organ procurement support, protocol development, hospital development, education, putting the protocol into practice, follow-up, and effect of the program on organ procurement. With the establishment of this program, the number of non-heart-beating donors increased from 2% to 5% per year to over 10% for the past 2 years. From these donors, 61 of 82 recovered kidneys were transplanted into 58 patients, and 18 of 20 recovered livers were transplanted. A non-heart-beating donor program can significantly add to the number of organ transplants and successful transplantations.     

Complicated acute type B dissections--an 8-years experience of endovascular stent-graft repair in a single centre.

OBJECTIVE: To analyze the experience of a single centre using stent-grafts for treatment of complicated acute aortic type B-dissections (EVR-ABD). DESIGN: Retrospective analysis of prospectively collected data from patients undergoing EVR-ABD between January 1997 and December 2004. METHODS: EVR-ABD was performed in 31 patients (20 males, median age 74 years (IQR: 64-79)). Indications for treatment were aortic rupture (22 patients), intractable pain and hypertension (six patients), acute bowel ischemia (two patients) and transient paraplegia, lower limb and renal ischemia in one patient. Initially home-made devices (five patients) and subsequently commercially available thoracic stent-grafts were used. RESULTS: Five patients (16%) died within 30 days of EVR-ABD. Postoperative complications occurred in 15 (48%) patients, including one paraplegia converted to paraparesis after cerebrospinal fluid drainage, five strokes, three lower limb ischemia, three myocardial infarction, two pneumonia and one colitis). Re-interventions were required in nine patients (29%). Six more deaths occurred during a median follow-up of 22 (IQR: 16-34) months, two related to the stent-graft and four due to cardiac disease. CONCLUSIONS: Stent-graft repair of complicated acute type B dissections seems to provide acceptable results and, therefore, it may be considered a valuable alternative to open surgery.     

实施护理专案缩短急性脑梗死患者血管内取栓时间

目的通过护理专案活动缩短急性缺血性脑卒中患者血管内取栓时间。方法成立护理专案小组,调查2018年1～3月31例(对照组)急性缺血性脑卒中患者经绿色通道行血管内取栓的现状,对2018年10～12月41例急性缺血性脑卒中患者(干预组)开展护理专案改善活动,进行原因分析和目标制定,拟定对策并实施。结果干预组入室至穿刺时间、穿刺至再通时间显著短于对照组(均P0.01)。结论通过护理专案活动,可将急性缺血性脑卒中血管内取栓患者入室-穿刺-再通的工作流程细化、完善,规范护理干预措施,有效缩短了AIS患者血管内取栓时间。     

Mycobacterium infection directly observed in a surgical outpatient centre

BACKGROUND: This study aims to check the presence and the role of the Mycobacterium tuberculosis infection, in an Ambulatory and Day Surgery Out-Patient Centre. METHODS: Two periods of activity in this Centre are evaluated corresponding separately to the years 1989-1993 and 1994-1998 and the total number of patients, coming for examination, ambulatory or day surgery, hospitalization, postoperative follow-up, is considered, in order to identify the number of cases and the clinical signs of this disease. All cases were examined by the same team and the checks were completed, in the selected cases in which it was advisable, with radiological, bacteriological, bioptical, radiometrical exams and with the Elisa test (after informed consent). RESULTS: In the first period 1989-1993, 21,220 patients were examined and no case of tubercular infection was observed. In 1994-1998, 24,347 patients were examined and 4 cases of tubercular infection detected, which represent 0.016% of the patients attending the service. The clinical cases are as follows. Case 1: right sub-mammary lump, diameter 7 x 5 cm, smooth, oval, firm. Case 2: right breast swelling, diameter 5 cm, not sore, with deep attachments. The mammography and ultrasound scan indicate: the opacity is compatible with mali moris breast lesion. Case 3: coloured, immigrant, who presents back swelling, diameter 8 cm, with fluctuation. CT of the chest indicates opacity near left latissimus dorsi muscle, diameter 10 cm, without bronchopleural connections. Case 4: bleeding neoplastic ulcer of the wrist. At physical exam a right subclavear amphoric breath sound is noticed, corresponding at chest X-ray to an opacity including cavitation. In the 4 cases no lymph node in the regional effusion areas is detected. In the 4 cases surgical therapy is integrated with antituberculous chemotherapy till 6 months after operation. CONCLUSIONS: Mycobacterium tuberculosis infection has been increasing in the second group of years considered, as it is observed in European industrialized countries and North America. This increase corresponds to 0.016% in 24,374 patients examined in the period 1994-98. This infection must not be connected with the classic sites and traditional primary and post-primary symptons, but must be considered and identified in a surgical hospital out-patient centre, in unusual sites, sometimes masquerading as a false positive carcinoma, in patients with predisposition, because of old age, race, immunodepression (also if HIV negatives), resistance to treatment, previous tuberculous infection. In the cases identified deep diagnostic definition, the surgical treatment and a prolonged antituberculous chemotherapy are necessary.