Competency in laparoscopic colorectal surgery is achievable with appropriate training but takes time: a comparison of 300 elective resections with anastomosis

Aim The aim of this retrospective cohort study was to compare outcomes in patients who underwent elective laparoscopic colorectal resection with anastomosis performed by a single surgeon or his training fellow. Method A prospective electronic database of all laparoscopic procedures between January 2005 and September 2008 was used. Two groups were compared; those patients operated upon by the Consultant trainer (C) and those by seven supervised Fellows (F). Fellows were either post CCT or in their last year of training. Three hundred consecutive patients undergoing laparoscopic colorectal resection with anastomosis were examined, 150 in each group. Groups were matched for indication, age, American Society of Anesthesiology (ASA) grade, cancer T stage and resection performed. Preoperative work‐up, operative surgery and anaesthesia were identical between groups. Results No significant difference was demonstrated in age, mean 67 (26–91) or ASA grade. Indications for surgery were; cancer (C) 120, (F) 126, diverticular disease (C) 22, (F) 20, Crohn’s disease (C) 8, (F) 7. Fellow’s mean operative time was significantly longer at 123 min (95%CI 117–134) compared to the consultant trainer −105 min. (95%CI 98–111): P < 0.01). No significant differences in the complication or conversion rates were demonstrated. Length of stay and the 30‐day readmission rates were similar. Conclusion In this retrospective cohort study we have demonstrate that when matched patients are compared, supervised trainee operating time is significantly longer than that of the consultant trainer but without any significant increase in length of stay, complication or readmission rates. Training to a level of competency takes time but not at the expense of patient care.     

Fibrinolytic administration for acute myocardial infarction in a tertiary ED: factors associated with an increased door-to-needle time

The purpose of this study was to evaluate the door-to-needle time for fibrinolytic administration for acute myocardial infarction (AMI) at Vancouver General Hospital (VGH) and identify factors associated with time prolongation. A retrospective chart review of all patients fibrinolysed for AMI in the ED at VGH was performed from January 1, 1998, to December 31, 1999, to determine door-to-needle time. A mixed-effects linear regression model was fit to the fibrinolytic data with the door-to-needle time to identify factors associated with prolonged times. One hundred forty patients were included in the final analysis. The mean and median door-to-needle times were 58 and 43 minutes, respectively. A door-to-needle time of under 30 minutes was achieved in 24.3% of patients, 30 to 40 minutes in 24.3%, 40 to 60 minutes in 22.1%, and over 60 minutes in 29.3%. EP prescribers without prior cardiologist consultation resulted in a significantly shorter door-to-needle time compared with requesting a cardiology consult before administration (mean [median] 41 [35] minutes vs. 108 [90] minutes respectively; P <.001). Patients who arrived by ambulance had shorter door-to-needle times than those who did not (mean [median] 50 [38] minutes vs. 71 [57] minutes, respectively; P =.008). Patients who arrived during the night shift (2300-0700 hrs) had significantly shorter door-to-needle times than those patients who arrived during the day (0700-1500 hrs) or afternoon (1500-2300) shifts (P = 0481); and patients who had a longer time from chest pain onset to ED arrival also had longer door-to-needle times (P =.0233). A significant number of AMI patients fibrinolysed at VGH do not meet the national guideline for door-to-needle time less than 30 minutes. Factors associated with this should be addressed to improve the care of patients with AMI.     

Management of pediatric occult pneumothorax in blunt trauma: a subgroup analysis of the American Association for the Surgery of Trauma multicenter prospective observational study

BackgroundOccult pneumothorax (OPTX) represents air within the pleural space not visible on conventional chest radiographs. Increased use of computed tomography has led to a rise in the detection of OPTX. Optimal management remains undefined.MethodsA pediatric subgroup analysis (age <18 years) from a multicenter, observational study evaluating OPTX management. Data analyzed were pneumothorax size, management outcome, and associated risk factors to characterize those that may be safely observed.ResultsFifty-two OPTX (7.3 ± 6.2 mm) in 51 patients were identified. None were greater than 27 mm; all those under 16.5 mm (n = 48) were successfully managed without intervention. Two patients underwent initial tube thoracostomy (one [21 mm] and the other with bilateral OPTX [24 mm, 27 mm]). Among patients under observation (n = 49), OPTX size progressed in 2; one (6.4mm) required no treatment, while one (16.5 mm) received elective intervention. Respiratory distress occurred in one patient (10.7 mm) who did not require tube thoracostomy. Nine received positive pressure ventilation; 8 did not have a tube thoracostomy. Twenty-four patients (51%) had one or more rib fractures; 3 required tube thoracostomy.ConclusionNo pediatric OPTX initially observed developed a tension pneumothorax or adverse event related to observation. Pediatric patients with OPTX less than 16 mm may be safely observed. Neither the presence of rib fractures nor need for PPV alone necessitates intervention.     

Drug-related hospitalizations in a tertiary care internal medicine service of a Canadian hospital: a prospective study

STUDY OBJECTIVES: To determine the frequency, severity, preventability, and classification of adverse drug events resulting in hospitalization, and to identify any patient, prescriber, drug, and system factors associated with these events. DESIGN: Prospective, observational study. SETTING: Internal medicine service of a large tertiary care hospital in Canada. PATIENTS: A total of 565 consecutive adult patients admitted to the hospital during a 12-week period. MEASUREMENTS AND MAIN RESULTS: A patient's hospitalization was defined as drug related if it was directly related to one of eight predefined classifications; severity and preventability of the hospitalization were also assessed. Multivariate logistic regression analysis was used to evaluate patient, prescriber, drug, and system factors associated with drug-related hospitalizations. The frequency of drug-related hospitalization was 24.1% (95% confidence interval [CI] 20.6-27.8%), of which 72.1% (95% CI 63.7-79.4%) were deemed preventable. Severity was classified as mild, moderate, severe, and fatal in 8.1% (95% CI 4.1-14.0%), 83.8% (95% CI 76.5-89.6%), 7.4% (95% CI 3.6-13.1%), and 0.7% (95% CI 0.0-4.0%), respectively, of the hospitalizations. The most common classifications of drug-related hospitalization were adverse drug reactions (35.3% [95% CI 27.3-43.9%]), improper drug selection (17.6% [95% CI 11.6-25.1%]), and noncompliance (16.2% [95% CI 10.4-23.5%]). No independent risk factors for drug-related hospitalization were identified with regression modeling. CONCLUSION: Approximately 25% of patients in our study were hospitalized for drug-related causes; over 70% of these causes were deemed preventable. Drug-related hospitalization is a significant problem that merits further research and intervention.     

Relation between the presence and extent of coronary lipid core plaques detected by near-infrared spectroscopy with postpercutaneous coronary intervention myocardial infarction

We aimed to examine whether an association exists between the presence and extent of coronary lipid core plaques (LCPs) detected by near-infrared spectroscopy (NIRS) performed before percutaneous coronary intervention (PCI) with postprocedural myocardial infarction (MI). NIRS was performed in the native coronary arteries of 30 patients before PCI. Angular extent of LCP, lesion segment lipid core burden index, and block chemogram were evaluated. Cardiac biomarkers were measured before and 16 to 24 hours after PCI to determine occurrence of postprocedural MI. Mean number of 2-mm yellow blocks within the stented lesion was 1.4 ± 2.1 and mean lesion lipid core burden index was 110.3 ± 99. Using a definition of creatine kinase-MB >1 time upper limit of normal (ULN), >2 times ULN, and >3 times ULN, MI after PCI occurred in 23%, 13%, and 10% of patients, respectively. Compared to patients who did not have MI after PCI, those who did had similar clinical characteristics but received more stents and had more blocks within the stented lesion. Creatine kinase-MB increase >3 times ULN was observed in 27% of patients with ≥1 yellow block versus in none of the patients without a yellow block within the stented lesion (p = 0.02). In conclusion, PCI of LCP-positive lesions as assessed by NIRS is associated with increased risk for MI after PCI. NIRS may allow lesion-specific risk stratification before PCI and optimization of PCI strategies for myocardial injury risk minimization.     

Effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation

In this post hoc analysis, we assessed effects of thrombolysis during out-of-hospital cardiopulmonary resuscitation. The original study was designed as a double-blinded, prospective, multicenter, randomized, controlled clinical trial. In this report, 1,219 patients were randomized, but 33 patients were excluded due to missing study drug codes. Thus, 1,186 patients were analyzed based on receipt (n = 99) versus nonreceipt (n = 1,087) of thrombolysis; the primary end point was hospital admission, and the secondary end point was hospital discharge. Patients who received thrombolysis versus those who did not were significantly younger (mean +/- SD 62.7 +/- 13.3 vs 66.5 +/- 14.3 years of age, p = 0.01) and more likely to have had an acute myocardial infarction (75.3% vs 54.6%, p < 0.01) or pulmonary embolism (20.2% vs 12.0%, p = 0.03) as the suspected underlying cause for cardiac arrest. In patients who underwent thrombolysis versus those who did not, cardiac arrest was more often witnessed (86.9% vs 77.5%, p = 0.03), initial ventricular fibrillation was more likely (59.6% vs 38.0%, p < 0.01), and a short estimated interval (0 to 5 minutes) between collapse and initiation of basic life support was more likely (51.3% vs 29.2%, p < 0.01). In patients who received thrombolysis, sodium bicarbonate (45.5% vs 33.0%, p = 0.01), lidocaine (32.3% vs 18.1%, p < 0.01), and amiodarone (30.3% vs 12.2%, p < 0.01) were administered significantly more often. Hospital admission rates were significantly higher in patients who underwent thrombolysis than in patients who did not (45.5% vs 32.7%, p = 0.01), and there was a trend to higher hospital discharge rates (14.1% vs 9.5%, p = 0.14). In patients who had suspected myocardial infarction, hospital admission and discharge rates were significantly higher in patients who underwent thrombolysis than in patients who did not. In logistic regression models after adjusting for confounding variables (e.g., age, initial electrocardiographic rhythm, and initiation of basic life support), hospital admission and discharge rates did not differ significantly. In conclusion, even when being employed in patients with a potentially better chance to survive, thrombolysis in patients with cardiac arrest resulted in an increased hospital admission but not discharge rate in this post hoc analysis.