International surgical clerkship rotation: perceptions and academic performance

Background

Concerns about international training experiences in medical school curricula include the effect on student learning. We studied the educational effect of an international elective integrated into a traditional third-year (M3) surgical clerkship.

Methods

A 1-week surgical elective in Haiti was available to M3 students during the conventional 8-week surgical clerkship each year for the 4 academic years 2008 to 2011. The authors collected student and surgeon perceptions of the elective using a mixed-methods web-based survey. Statistical analysis compared the academic performance of participating M3s relative to nonparticipating peers.

Results

Twenty-eight (100%) students (41 trip weeks) and 3 (75%) surgeons responded. Twenty-five (89%) students believed the elective provided appropriate clinical training. Surgeon responses were consistent with students' reported perceptions.Strengths included unique clinical experiences and close interactions with faculty. Criticisms included recurring overwhelming clinical responsibilities and lack of local provider involvement.Academic performance of participants versus nonparticipants in the same clerkship term were statistically insignificant.

Conclusions

This study demonstrates the feasibility of integrating global health experiences into traditional medical student clinical curricula. The effects on less tangible attributes such as leadership skills, fostering teamwork, and cultural competency require future investigation.     

Educational value of the operating room experience during a core surgical clerkship

Background

The amount and content of medical student teaching in the operating room and its alignment with clerkship goals was unknown.

Methods

A qualitative research design using field observations, followed by qualitative and quantitative data coding and analysis.

Results

A mean of 9.8% of the total case time (range 1.6%-20.2%) was spent teaching clerkship goals. Teaching strategies based on basic principles of learning were used during a mean of 66% of the total case time (range 30%-99%). The most common teaching strategy was active student participation (28%) followed by command (14%) and lecture (13%). Educational experience in the OR was rated 4.0 (out of 5) by faculty and 3.3 by students. No correlation existed between student satisfaction and time actively participating in the operation or time spent teaching to clerkship goals (P = .66, P = .95, respectively).

Conclusion

Teaching in the OR is more focused on technical aspects of the operation than the goals of a core surgery clerkship.     

Caecal volvulus

Background

Caecal volvulus accounts for 30% of all cases of volvulus of the colon.

Methods

We recorded clinical data and accurate images of volvulus of the cecum.

Results

A detorsion with resection and primary anastomosis was performed. We reviewed the management and surgical strategies for cecal volvulus.

Conclusions

Caecal volvulus is an uncommon entity with potentially severe outcomes and requires surgical management.     

A situational overview of surgical quality and safety in 2010

Background

Surgical safety and quality initiatives have now moved to the front of the agenda for contemporary surgery.

Methods

Sixty-two surgical specialists began to study quality and cost control in 1998, and those efforts grew into a Centers for Medicare and Medicaid Services-funded pilot study of the Surgical Care Improvement Project in 2004. Subsequent symposia and studies evolved.

Results

A greater awareness of the issues and methods for meaningful improvement of surgical safety in nearly 25,000 specialty surgeries have been described in numerous peer-reviewed publications.

Conclusions

Surgeon-initiated efforts have led to marked improvements in multiple specialties and in many small and large hospitals and academic training centers.     

The July effect and cardiac surgery: the effect of the beginning of the academic cycle on outcomes

Background

The effect of the time of the academic year on cardiac surgical outcomes is unknown.

Methods

Using prospectively collected data, we identified all (n = 1,673) cardiac surgical procedures performed at our institution between October 1997 and April 2007. Morbidity and mortality rates were compared between 2 periods of the academic year, one early (July 1-August 31, n = 242) and one later in the year (September 1-June 30, n = 1,431). A prediction model was constructed by using stepwise logistic regression modeling.

Results

Morbidity rates did not differ significantly between the early (12.8%) and later periods (15.4%) (odds ratio [OR], 0.83; 95% confidence interval [CI], 0.54-1.28; P = 0.3). Additionally, there was no significant difference in operative mortality between the early (1.2%) and later periods (3.5%) (OR, 0.28; 95% CI, 0.07-1.19; P = 0.06).

Conclusions

The early and later parts of the academic year were associated with similar risk-adjusted outcomes. Further studies are needed to determine whether our findings are applicable to other academic cardiac centers.     

Transumbilical pyloromyotomy with umbilicoplasty provides ease of access and excellent cosmetic results

Background/Purpose

Cosmesis is considered one of the key reasons to perform pyloromyotomies through the umbilicus. We describe the results of pyloromyotomy using a supraumbilical incision with umbilicoplasty that allows ease of mobilization of the pylorus and excellent cosmetic results.

Methods

The charts of all patients undergoing transumbilical pyloromyotomy with umbilicoplasty from 2002 to 2006 were retrospectively reviewed. Demographic data as well as operative time, details of surgical technique, and outcome were collected and analyzed.

Results

Thirty-eight patients underwent a transumbilical pyloromyotomy with umbilicoplasty. The average operative time was 39.2 minutes (range, 11-66 minutes). The time to tolerating feeds was 1.14 days (range, 1-3 days), and the average length of stay was 1.84 days (range, 1-8 days). There were 2 complications: periumbilical cellulitis (n = 1) and incisional hernia (n = 1). There were no perforations and no incomplete pyloromyotomies. The cosmetic results on postoperative follow-up were subjectively excellent.

Conclusions

Transumbilical pyloromyotomy with umbilicoplasty combines ease of exposure with ease of mobilization of the pylorus. There is minimal morbidity and an excellent cosmetic result. Time to average feeding, length of stay, and complications are similar to published reports of both open and laparoscopic pyloromyotomy.     

State of the practice for pediatric surgery--career satisfaction and concerns. A report from the American Pediatric Surgical Association Task Force on Family Issues

Background

There has been increasing interest and concern raised in the surgical literature regarding changes in the culture of surgical training and practice, and the impact these changes may have on surgeon stress and the appeal of a career in surgery. We surveyed pediatric surgeons and their partners to collect information on career satisfaction and work-family balance.

Methods

The American Pediatric Surgical Association Task Force on Family Issues developed separate survey instruments for both pediatric surgeons and their partners that requested demographic data and information regarding the impact of surgical training and practice on the surgeon's opportunity to be involved with his/her family.

Results

We found that 96% of pediatric surgeons were satisfied with their career choice. Of concern was the lack of balance, with little time available for family, noted by both pediatric surgeons and their partners.

Conclusion

The issues of work-family balance and its impact on surgeon stress and burnout should be addressed in both pediatric surgery training and practice. The American Pediatric Surgical Association is positioned to play a leading role in this effort.     

Analysis of Reoperations and Their Impact on the Results of Pancreas Transplantation

Background

Many factors, including the advances in surgical techniques and immunosuppression, have been brought significant improvement to graft and patient survivals of patients undergoing pancreatic transplantations. However, one third of these patients require reoperations (ReOps).

Purpose

We sought to evaluate the distribution of ReOps in the early or late postoperative period and analyze their impact on patient and graft survivals.

Patients and Methods

This unicenter, retrospective study was performed using data from 182 patient charts after pancreas transplantation from January 2000 through December 2007.

Results

We performed 88 ReOps on 73 patients; 43 early and 41 late operations. The simultaneous pancreas-kidney transplantation group showed a greater incidence of premature ReOps. The group undergoing early ReOp showed a lower survival rate (87.2%) compared with the nonoperated group, but a similar survival rate (97.5%) to the late ReOp group. In relation to the survival of pancreatic grafts after 1 year, the early ReOp group showed inferior survival to the late ReOp group, both of which were significantly worse results then those of the group without ReOp.

Conclusion

ReOps were related to the success of the procedure. When they were performed in the first 3 months they had a negative impact on patient and graft survival.     

Are mastectomy rates a reasonable quality measure of breast cancer surgery?

Background

Quality measures of breast cancer clinical management adopted by the National Quality Forum do not address the quality of surgical performance. We evaluated mastectomy rate as one potential quality indicator.

Methods

We reviewed the surgical management of small (stage T1; ≤2 cm) invasive breast tumors in patients treated from April 2003 through April 2007 at our institution. For patients undergoing mastectomy, factors leading to the selection of mastectomy were analyzed.

Results

We identified 496 patients with invasive breast cancer: 433 did not undergo neoadjuvant chemotherapy, and 319 of these had pathologic tumors ≤2 cm in size. Of these, 55 (17.2%) underwent initial mastectomy. Medical contraindications to breast conservation were identified in 42 of 319 (13.2%) patients, whereas the selection of mastectomy was attributed to patient choice in 13 of 319 (4.1%) patients.

Conclusions

Medical contraindications to breast-conserving therapy were much more common than patient choice as the indication for mastectomy. Institution- or surgeon-specific mastectomy rates are unlikely to reflect the complexity of decision making in the surgical management of patients with breast cancer.     

Twenty-eight-day mortality in critically ill surgical patients is an imprecise temporal end-point measure for in-hospital mortality

Background

The purpose of this study was to determine the incidence of deaths occurring beyond 28 days in critically ill surgical patients and to identify the proportion of these deaths attributable to the original disease process.

Methods

Analysis of 1,360 subjects admitted to a surgical intensive care unit during a 2 year period. Demographics, indication(s) for admission, comorbidities, mortality rate, multiorgan failure development, and cause of death was obtained.

Results

Mortality rate in the surgical intensive care unit was 12%. Twenty % of deaths occurred more than 28 days after hospital admission with 76% of deaths related to admission diagnosis. By day 34, 95% of mortalities had occurred.

Conclusions

The 28-day time period used to assess efficacy of therapeutic interventions and to define mortality in the context of quality audits should be questioned. If these findings are validated in other centers another temporal end point for in-hospital mortality should be considered.     

Laparoscopic unroofing of splenic cysts results in a high rate of recurrences

Purpose

Laparoscopic unroofing is described as an appropriate treatment modality of nonparasitic splenic cysts. However, we repeatedly encountered recurrences with this technique. Because splenic cysts are rare, we analyzed the combined experience of 3 German pediatric surgical departments.

Materials and Methods

Between 1995 and 2005, primary and secondary nonparasitic splenic cysts were unroofed laparoscopically in 14 children (aged 5-12 years; median, 8.5 years). In 3 patients, the inner surface was coagulated with the argon beamer. In most children, the cavity was surfaced with omentum. In addition, in 4 patients the omentum was sutured to the splenic parenchyma.

Results

No intraoperative complications occurred, and no inadvertent splenectomy or blood transfusions were necessary. However, in 9 children (64%) the cysts recurred at intervals ranging from 6 to 12 months (median, 12 months). Also, argon laser treatment of the surface resulted in recurrence.

Conclusion

Laparoscopic unroofing of true splenic cysts alone proved inadequate in this series. Either removal of the inner layer or partial splenectomy appears to be necessary to prevent recurrences.     

Pediatric rib lesions: a 13-year experience

Background

Rib lesions in the pediatric population are rare but significant processes and are often neoplastic.

Methods

All patients with primary rib lesions evaluated by the Department of Surgery at Children's Hospital Boston from 1992 to 2005 were studied. The patient's diagnosis, sex, symptoms and their duration, radiologic evaluation, biopsy status, surgical procedure, and follow-up were assessed.

Results

Thirty-three patients, ages 3 to 23 years (median, 12.7 years), were evaluated. Sixteen patients (48%) had benign and 17 (52%) had malignant lesions. Within the benign cohort of 16 patients, there were 6 osteochondromas, 4 aneurysmal bone cysts, and 2 fibrous dysplasias as well as 1 of each of the following: enchondroma, periosteal chondroma, eosinophilic granuloma, and chondrophyte. Within the malignant cohort of 17 patients, 13 were diagnosed with Ewing's sarcoma, 3 with osteogenic sarcoma, and 1 with chondrosarcoma. The sex distribution for the malignant group was 11 (65%) females and 6 (35%) males.

Conclusions

Rib tumors are rare entities in the pediatric population. However, a significant number of rib lesions are malignant. Therefore, proper diagnosis and expeditious treatment are critical.     

Sealants after axillary lymph node dissection for breast cancer: good intentions but bad results

Background

This study was conducted to evaluate the effect of 2 surgical sealants on postsurgical drainage and lymphocele formation after axillary surgery for breast cancer.

Methods

This was a prospective, randomized study. Seventy-seven consecutive patients with breast cancer were included and randomized into a control group (18F vacuum drain) and 2 study groups (18F vacuum drain plus COSEAL or BioGlue).

Results

The 3 groups were matched. Neither postsurgical drainage nor time to drain removal was affected by the use of either of the 2 sealants. Although no statistically significant difference in lymphocele formation and wound infection was noted, complications caused by intense foreign-body reaction that led to surgical intervention occurred in both study groups.

Comments

The use of surgical sealants is not recommended after axillary lymph node dissection for breast cancer. Complications of their use may lead to reoperation.     

Serum growth factors and growth indices pre- and post-pediatric intestinal transplantation

Background/purpose

Although intestinal transplantation (ITx) has succeeded in liberating children with intestinal failure from total parenteral nutrition (TPN), positive growth has yet to be achieved in the majority of patients. This investigation aims to evaluate levels of serum growth factors as they relate to growth parameters and nutritional outcomes.

Methods

Serum measures of insulin-like growth factor 1 (IGF-1) and insulin-like growth factor binding protein 3 (IGFBP-3) that had been obtained before and after transplantation were reviewed (with Institutional Review Board approval) in a subset of pediatric ITx recipients. Z-scores for weight and height were calculated at transplant and biannually thereafter for 2 years.

Results

Five children received a small bowel/liver transplant between August 1996 and March 2000 (median age, 1.3 years). Before transplantation, levels of IGF-1 and IGFBP-3 were low in 60% and 67% of patients, respectively. Posttransplant levels of these growth factors were within normal limits or elevated in all but 2 patients (IGFBP-3 only). A positive trend in z-scores was observed in just one of 5 patients for weight and in 2 of 5 for height/length during the follow-up period. Of the 3 patients who experienced negative linear growth velocity over time, 2 had low pretransplant levels of both IGF-1 and IGFBP-3. All patients were weaned from TPN within 3 months after transplant.

Conclusions

Pretransplant levels of growth mediators may be predictive factors in children who will require an intensive regimen of nutritional rehabilitation posttransplant to promote the growth process. Absorption studies may aid in determining the appropriate nutrient substrates for the post-ITx population.     

Preincisional local infiltration of tramadol at the trocar site versus intravenous tramadol for pain control after laparoscopic cholecystectomy

Study Objective

To compare the effects of preoperative intravenous (IV) tramadol and preoperative tramadol infiltration of trocar sites on postoperative pain and postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy.

Design

Prospective, randomized study.

Setting

Operating room, recovery room, and surgical ward.

Patients

70 ASA physical status 1 and 2 patients, aged 20-70 years, scheduled for elective laparoscopic cholecystectomy.

Interventions

In Group I, patients received IV 2.0 mg/kg of tramadol; in Group II, trocar insertion points were infiltrated with 2.0 mg/kg of tramadol in 20 mL of 0.9% NaCl.

Measurements

Pain scores, sedation scores, postoperative analgesic requirement, and PONV were recorded at 0 and 30 minutes and one, three, 6, 12, and 24 hours. At 30 minutes and one hour, pain localization (incisional or diffuse abdominal) was also recorded.

Main Results

Visual analog scale scores at 30 minutes were significantly lower in Group II [3 (0-7)] than Group I [6 (3-8)] (P < 0.001). In Group I, 91.4% of patients received sodium diclofenac, while 68.6% of Group II patients received sodium diclofenac (P = 0.002). The time to first analgesic requirement was significantly lower in Group II (P = 0.004). At the 30-minute measurement time, a significant difference was recorded between the groups in incisional pain (P < 0.001). There was also a significant difference between groups in the frequency of PONV.

Conclusions

Trocar site infiltration of tramadol improves early postoperative pain and decreases PONV.     

Evaluation of pectus bar position and osseous bone formation

Purpose

Minimally invasive repair has become a popular approach for pectus excavatum (PE). The bar is secured to the thoracic wall and left for approximately 2 years. The authors have noticed an intense bone formation (BF) around some of these bars at removal. A review of children undergoing bar removal was performed to better understand this BF in relation to bar placement.

Methods

A retrospective review of children undergoing bar removal after PE repair since January 1998 was performed. Chart review included age at bar insertion and removal, bar insertion position (subcutaneous [SC] v submuscular [SM]), BF on Chest x-ray and at bar removal, operating time, and estimated blood loss (EBL).

Results

Thirty-six patients underwent bar removal during the study period (16 SC and 20 SM). Chest x-ray evaluation was possible in 27 patients (16 SM, 11 SC). No difference existed for length of time the bar was in place or age at insertion/removal between groups. EBL was higher in the SM (18.3 v 8.8 mL, not significant). BF was seen radiographically in 15 SM and 3 SC patients (P < .001). BF was encountered at removal in 19 SM patients and a single SC patient (P < .001). Operating time was statistically longer (P < .01) for the SM group (30.2 v 15.6 min).

Conclusions

Bar position during repair of PE is important. SM positioning virtually always results in BF with increased EBL and statistically longer operating time at removal. Careful placement of the bar in the SC position without violating the fascia should be used to avoid these undesirable effects.     

Laparoscopy-assisted surgery for prenatally diagnosed small bowel atresia: simple, safe, and virtually scar free

Purpose

The aim of this study was to describe a new technique for the surgical management of prenatally diagnosed small bowel atresia.

Methods

Under general anesthesia, a 5-mm trocar was inserted using an open technique through an intraumbilical incision. The proximal atretic bowel end was identified using laparoscopy and mobilized toward the umbilicus using an additional 3-mm trocar inserted in the left lower quadrant. The umbilical trocar then was removed, and a ring retractor was inserted into the trocar site and used to expand the wound to deliver both atretic bowel ends. The bowel was repaired and returned to the abdomen through the umbilical wound. The umbilical fascia and skin were closed conventionally.

Results

Three patients were reviewed. Two had minimal abdominal distension, and the atretic bowel ends could be identified easily; laparoscopy-assisted surgery was successful. The third case had significant dilatation, and laparotomy was required. Postoperatively, there was minimal abdominal scarring, and the umbilicus was normal in appearance.

Conclusions

Although this experience is limited to 3 patients, this technique is simple, safe, and virtually scar free and can be applied for the treatment of neonates with prenatally diagnosed small bowel atresia, especially if there is minimal abdominal distension at birth.     

Extended left hepatectomy of the left and middle hepatic venous drainage areas along the anterior fissure

Background

Extended left hepatectomy including the middle hepatic vein (MHV) may potentially induce right paramedian sector congestion of the remnant liver.

Methods

To prevent venous congestion in the right paramedian sector, we performed extended left hepatectomy including the left hemiliver and anterior segment, which drain into the MHV and left hepatic vein (LHV), for 15 patients.

Results

In 11 of 15 patients (73%), temporary clamping of the common trunk of the MHV and LHV and the proper hepatic artery provided the anterior fissure. Regeneration rate of the middle segment was similar to that of the right lateral sector (10.8% vs 11.2%) on postoperative computed tomography (CT) after 3 months.

Conclusions

This procedure could represent a useful method for preventing postoperative venous congestion.     

Intravenous landiolol, a novel β(1)-adrenergic blocker, reduces the minimum alveolar concentration of sevoflurane in women

Study Objective

To investigate the effect of intravenous (IV) landiolol, a novel β₁-adrenergic blocker, on the minimum alveolar concentration (MAC) of sevoflurane in adult women.

Design

Prospective, randomized study.

Setting

University hospital.

Patients

42 ASA physical status 1 and 2 women, aged 24-57 years, who were scheduled to undergo elective abdominal surgery.

Interventions

Anesthesia was induced in all patients by vital capacity rapid inhalation induction of sevoflurane. In the landiolol group, administration of landiolol began when patients took a vital-capacity breath: 0.125 mg/kg/min for one minute and then 0.04 mg/kg/min. Normal saline was administered in the control group.

Measurements

MAC was determined by a technique adapted from the conventional up-down method.

Main Results

The MAC of sevoflurane was 2.2% ± 0.2% in the control group and 1.7% ± 0.2% in the landiolol group, a statistically significant difference (P = 0.0005).

Conclusions

IV landiolol reduces the MAC of sevoflurane in women by approximately 20%.     

Current management of adolescent pilonidal disease

Background

Controversy persists regarding the optimal management for adolescent pilonidal disease. We reviewed the outcome of wide local excision (WLE) vs unroofing and marsupialization (UM) for pilonidal disease.

Methods

A retrospective review 2002 to 2007 of adolescents undergoing surgical treatment of pilonidal disease was performed. Data were analyzed using Student's t test.

Results

Twenty-six patients were treated for pilonidal disease during this period. Average age was 16.7 years (range, 14-19 years) with 50% males. Nine patients underwent WLE and 17 had UM. Before initial evaluation, 44% of patients in the WLE group had drainage of acute abscess compared to 59% in the UM group (P > .05). Postoperative complications in the WLE group (78%) were significantly higher compared to the UM group (0%). Median time for final healing was significantly higher in the WLE group (32 weeks) compared to the UM group (6 weeks). The reoperative rate was also significantly higher in the WLE group (56%) compared to the UM group (0%). No patient had recurrent disease after complete healing in either group.

Conclusion

Unroofing and marsupialization for primary pilonidal disease has a shorter time to heal and carries a lower complication and reoperative rate compared to WLE.