Should surgical novices trade their retractors for joysticks? Videogame experience decreases the time needed to acquire surgical skills

Background Video game experience (VGE) has been identified as a possible predictive factor for surgical skill. We hypothesized that surgical novices with previous VGE would acquire new surgical skills faster than those without. Methods Fourth-year medical students (M4) and first-year surgical residents (PG-1) completed a survey asking about standard demographic data and previous VGE. Gamers had high VGE, defined as more than 3 h per week of videogame playing. Nongamers had little or no VGE. Both groups trained to proficiency on two tasks (AcquirePlace and Traversal) of the MIST-VR simulator, with proficiency defined as meeting previously validated criteria on two consecutive trials. The number of trials required to achieve proficiency for each task was recorded. Results The 26 participants included 11 M4s and 15 PG-1s: 17 males (8 gamers/9 nongamers) and 9 females (3 gamers/6 nongamers), mean age 27.8 years. There were no differences in time to proficiency between the M4 and PG-1 residents, and there were no significant differences in the relative number of gamers per gender. All participants eventually met proficiency criteria. The 11 gamers reached proficiency more quickly than the 15 nongamers (median 0 trials versus 6 trials, p = 0.01). Gamers scored lower than nongamers on their initial attempts. Women overall took longer to reach proficiency than did men (median 10 trials versus 0 trials, p = 0.002). When stratified according to VGE, female nongamers took longer to reach proficiency than male nongamers (median 11 trials versus 1 trial, p = 0.006) but among gamers, there was no difference between females and males (median 0 trials versus 0.5 trials, NS). Conclusion Previous VGE shortens time to achieve proficiency on two tasks on a validated surgical simulator. The possibility that VGE may ameliorate gender differences in length of time required to acquire surgical skills should be explored further.     

Changes of D-dimer after total hip arthroplasty in patients with and without intraoperative heparin

Introduction Marked activation of thrombosis is common in patients undergoing total hip arthroplasty, especially during reaming of the femur and after insertion of the femoral prosthesis. This suggests that management designed to minimize deep vein thrombosis and fatal pulmonary embolism after total hip arthroplasty should be focused on the period during insertion of the femoral component. In some previous studies, a low dose of heparin administered intraoperatively was shown to suppress the formation of fibrin. Objective The present study was performed to evaluate the influence of intraoperative heparin administration on the D-dimer level and on the prevention of pulmonary embolism after total hip arthroplasty. Material/methods A total of 22 and 26 consecutive patients respectively underwent total hip arthroplasty with and without intraoperative administration of unfractionated heparin. Postoperatively, all patients wore knee-high elastic stockings and were fitted with calf-to-thigh intermittent pneumatic compression devices. Active ankle flexion and extension exercises were commenced as soon as motor function recovered. None of the 48 patients received prophylactic anticoagulants postoperatively. Results There was a significant difference of the mean D-dimer level on the 1st day between the patients with and without intraoperative administration of heparin (8.9 ± 6.6 vs. 15.7 ± 12.7, P < 0.05). Although there were no patients with symptomatic deep venous thrombosis and pulmonary embolism, asymptomatic pulmonary embolism was detected by pulmonary perfusion scintigraphy in three patients who did not receive intraoperative heparin. The operative blood loss and postoperative drainage were similar in both groups and no bleeding complications were observed. In conclusion, we recommend a safe and inexpensive regimen comprising 1,000 U of intravenous unfractionated heparin intraoperatively, postoperative pneumatic compression, and early active mobilization for prevention of thoromboembolic complications after total hip arthroplasty.     

Surgically Managed Gastrointestinal Stromal Tumors: A Comparative and Prognostic Analysis

BACKGROUND: Tyrosine kinase inhibitors have been shown to have marked clinical efficacy in patients with unresectable or metastatic gastrointestinal stromal tumors (GIST). We performed a comparative and prognostic analysis of our experience with surgically managed GIST to determine factors associated with adverse oncologic outcomes. METHODS: Oncologic outcomes of 191 patients with primary GIST surgically managed between 1978 and 2004 at a single institution were reviewed. Prognostic factors were analyzed by Cox analysis (hazard ratio [HR] and 95% confidence interval [95% CI]) and included age, sex, disease presentation (asymptomatic vs. symptomatic), tumor site (stomach, small bowel, colorectal), disease extent (localized vs. metastatic) and risk levels (high, intermediate, low, very-low) assigned on the basis of size and number of mitoses according to current National Institutes of Health recommendations. Primary end points were disease-free survival (DFS) and disease-specific survival (DSS). RESULTS: A total of 186 patients (97%) had c-kit-positive GIST. There were 54% high, 22% intermediate, 18% low, and 8% very low risk GIST originating from the stomach (54%), small bowel (36%), and colon and rectum (10%). Median patient age was 65 (range, 13-91) years, and 108 subjects (57%) were male. Seventy-two percent of patients had symptomatic local disease, and 21% patients had synchronous metastases. Most (95%) underwent R0 resections of their primary tumor. Among 146 patients (76%) with localized disease at presentation undergoing R0 resection, the 5-year DFS was 65%. High-risk GIST (HR 12, 95% CI, 5-32, P < .0001), symptomatic presentation (HR 2.5, 95% CI, 1.1-6, P = .04), and GIST in the small bowel (HR 2.8, 95% CI, 1-5, P = .003) were independently associated with decreased DFS. After a median follow-up of 63 months among survivors, the 5-year DSS was 68%. High-risk disease (HR 14.3, 95% CI, 5-41, P < .0001), symptomatic presentation (HR 3.1, 95% CI, 1.2-7.9, P = .02), and GIST in the small bowel (2.6,3 95% CI, 1-5, P = .006) were independently associated with decreased DSS. CONCLUSIONS: High-risk GIST are associated with increased disease recurrence and decreased survival despite complete surgical resection. These patients should receive adjuvant therapy in the form of tyrosine kinase inhibitors.     

Survival and Health Outcomes After Cytoreductive Surgery With Intraperitoneal Hyperthermic Chemotherapy for Disseminated Peritoneal Cancer of Appendiceal Origin

BACKGROUND: Cytoreductive surgery with intraperitoneal hyperthermic chemotherapy for peritoneal carcinomatosis of appendiceal origin can alleviate symptoms and prolong survival. This aggressive therapy may impair patient quality of life (QOL). The purpose of this study was to monitor health outcomes before and after treatment. METHODS: Patients underwent cytoreductive surgery and intraperitoneal hyperthermic chemotherapy for peritoneal cancer. Patients completed questionnaires consisting of demographic information and the Functional Assessment of Cancer Therapy, the SF-36 Medical Outcomes Study survey, the Center for Epidemiologic Studies-Depression Scale, and the ECOG Performance Status Rating before (T1) and after surgery at 3 (T2), 6 (T3), 12 (T4), and 24 (T5) months. Time trends were assessed with the mixed model (SAS PROC MIXED) to allow use of all the observed data as well as to account for missing data. RESULTS: Fifty-eight patients (50% female) with a mean age 52.4 years (SD 12.6; range, 28-80) were assessed before surgery. Overall survival at 1 year was 78.7%. Emotional well-being improved over the study period, while physical well-being and physical functioning declined at T2 and then improved to near baseline levels at T3 and T4. Percentage of patients with depressive symptoms was as follows: T1 = 24%, T2 = 30%, T3 = 24%, and T4 = 33%. QOL scores improved over time. CONCLUSIONS: Although complications can affect short-term recovery, survival in appendix cancer patients with peritoneal cancer is good and for some can be achieved without major decrements in QOL at 1 year. Depressive symptoms and some physical limitations remain in surviving patients.     

Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method

BACKGROUND: Conservative treatment of anastomotic leakage after anterior resection of the rectum seems to be possible in patients who have no occurrence of generalized peritonitis. This report describes a new method of endoscopic management of large anastomotic leakage in these patients. METHOD: The main feature of this new method is the endoscopically assisted placement of an open-cell sponge connected to a vacuum device into the abscess cavity via an introducer device. The sponge system is changed every 48-72 h. RESULTS: Twenty-nine patients with an anastomotic leakage after anterior resection were treated with the endoscopic vacuum therapy. The total duration of endovac therapy was 34.4 +/- 19.4 days. The total number of endoscopic sessions per patient was 11.4 +/- 6.3. In 21 of the 29 patients, a protecting stoma was created at the primary operation. Four patients were treated successfully without the need of a secondary stoma. Definitive healing was achieved in 28 of the 29 patients. CONCLUSIONS: Endoscopic vacuum-assisted closure is a new efficacious modality for treating anastomotic leakage following anterior resection due to an effective control of the septic focus. Further studies will show if it is possible to reduce the high mortality rate of patients with anastomotic leakage through the avoidance of surgical reinterventions while at the same time preserving the sphincter function.     

Range of motion during the perioperative period in total knee arthroplasty

INTRODUCTION: This study focused on the change in the range of motion (ROM) during the perioperative period, i.e., the preoperative and intraoperative ROM, and that on discharge, and compared the difference between posterior cruciate ligament-retaining (PCLR) and -sacrificing (PCLS) prostheses. MATERIALS AND METHODS: In this prospectively randomized study, we compared the changes in the ROM in PCLR (n = 50) and PCLS (n = 50) total knee arthroplasties. RESULTS: The mean flexion in PCLR prostheses was 130.0 degrees preoperatively, 120.0 degrees intraoperatively, and 105.0 degrees at discharge, and 125.0 degrees , 120.0 degrees , and 100.0 degrees , respectively, in PCLS. The designs did not differ statistically in each period (P > 0.05). Both designs showed significant correlations between the preoperative and intraoperative ROM, and between the preoperative and discharge ROM. Only the PCLS showed a significant correlation between the intraoperative and discharge ROM, and a significant difference was observed in correlation of rank coefficient between the two prostheses (P < 0.001). CONCLUSIONS: The PCLS design has an advantage in rehabilitation planning because of the predictable changes in the ROM during the perioperative period, although the acquired average ROM at discharge did not differ statistically.     

Sagittal plane analysis of the open and closed methods in children with displaced supracondylar fractures of the humerus (a radiological study)

OBJECTIVES: The aim of this study was to compare the radiological outcome of open and close reduction and osteosynthesis methods in the treatment of type II and III supracondylar humerus fractures in childhood with respect to the immediate post-operative reduction quality in sagittal plane. METHOD: One hundred and forty four-pediatric patients with type IIb and III supracondylar humerus fractures treated at two centers between 1995 and 2005 were evaluated radiologically within a retrospective study. Seventy-six patients (54 boys, 22 girls, mean age 7.6, range 2-12) were treated by closed reduction and cross percutaneous pinning while 68 (49 boys, 19 girls, mean age 7.3, range 2-13) were treated by open reduction. The reduction quality of the open and closed groups was compared on immediate post-operative lateral radiographs by measuring of lateral humerocapitellar angle, anterior humeral line and anterior coronoid line criteria. The reduction quality was classified excellent, good, fair and poor according to the achievement of three, two, one or none of the criteria, respectively. Reductions classified as excellent and good were introduced as acceptable results. RESULTS: At least one criterion was achieved in all the patients of both the groups. The mean humerocapitellar angle was 30.1 degrees in closed reduction group while the mean of it was 29.8 degrees in open reduced group. Radiograph of 48 (63.1%) patients with closed reduction were found to display the anterior humeral line intersecting the middle one-third of capitellum while this criteria was 45 (66%) in open reduction group. The anterior coronoid line was disturbed in three patients in each of both the groups. The reduction quality was evaluated to be excellent in 32 patients, good in 31, fair in 13 at the closed reduction group while these evaluations were 31, 20 and 17 in open reduction group, respectively. Successful reduction was achieved in 74.9% of the patients in closed reduction group and 75% of the patients in open reduction group. CONCLUSION: It is concluded that there was no significant difference between closed and open reductions of pediatric displaced supracondylar fractures with regard to the radiological criteria of reduction quality in sagittal plane.     

Roux-en-Y gastric bypass procedure performed with the da Vinci robot system: is it worth it?

BACKGROUND: The Roux-en-Y gastric bypass procedure (RYGBP) is in many countries the gold standard for obtaining long-lasting weight reduction and improvement of obesity-related comorbidities. However, performing this operation by standard laparoscopic techniques requires important surgical skills because of the anastomoses involved. The da Vinci surgical robot system with its enhanced degrees of freedom in motion and three-dimensional vision is designed to overcome the difficulties encountered in traditional laparoscopic surgery with suturing and delicate tissue handling. METHODS: For this study, 45 patients (9 men) with a mean body mass index (BMI) of 44.2 (range, 35.1-55.4) underwent RYGBP with the aid of the da Vinci robot system. They were compared with 45 consecutive patients with a mean BMI of 43.9 (range, 35.1-56.2) who underwent a laparoscopic RYGBP by the same surgeon during the same period. RESULTS: Overall, the total operating time was shorter for the laparoscopic cases (127 vs 212 min; p < 0.05). However, the last 10 robotic cases were performed in the same time span as the laparoscopic cases (136 vs 127 min). The total robotic setup time remained constant at about 30 min. There were no differences in postoperative complications between the two groups in terms of anastomotic leakage or stenosis. In the robotic group, more conversions to open surgery were noted. Early in the study, four patients (9%) had to undergo conversion to standard laparoscopic techniques due to inadequate setup of the robotic arms. Five patients (11%), however, had to undergo conversion to open surgery because of intestinal laceration during manipulation of the intestines with the robotic instruments. The costs were higher for robotic surgery than for standard laparoscopic RYGBP, mainly because of the extra equipment used, such as ultrasonic devices. CONCLUSION: The RYGBP procedure can be performed safely with the da Vinci robot after a learning curve of about 35 cases. At this writing, however, it is not clear whether the da Vinci system offers a real advantage over standard laparoscopic techniques.     

Beneficial Effect of Partial Portal Decompression Using the Inferior Mesenteric Vein for Intractable Gastroesophageal Variceal Bleeding in Patients With Liver Cirrhosis

BACKGROUND: Use of the inferior mesenteric vein (IMV) for partial portal decompression has not been recommended as a first-line option for intractable gastroesophageal variceal bleeding because of the thin diameter of the vein. Although these indications remain relevant, few reports have compared partial portal decompression using the IMV with other therapies. We propose that partial portal decompression using the IMV is a useful alternative treatment for intractable variceal bleeding. METHODS: We performed partial portal decompression using the IMV in eight patients with intractable variceal bleeding that had been uncontrolled using medical and endoscopic therapies. All patients were classified into Child's class B or C. The surgical data, morbidity, and mortality were assessed. RESULTS: Mean portal venous pressure significantly decreased from 26.9 +/- 2.0 mmHg before the surgery to 19.8 +/- 3.9 mmHg after the surgery. The operative mortality rate was 0%. The mean duration of hospital stay was 25.5 +/- 13.3 days. Although one patient experienced recurrent bleeding, shunt patency was well maintained in all patients during the follow-up period (mean 28.9 +/- 14.1 months). Six patients are still alive and well without ascites or hepatic encephalopathy. Two of the Child's class C patients who underwent emergency shunt died owing to hepatic decompensation. CONCLUSION: Partial portal decompression using the IMV can be a safe, effective way to treat intractable variceal bleeding in patients with liver cirrhosis. However, use of the shunt procedure may have the most survival benefits for cirrhotic patients with preserved liver function.     

Thyroid-stimulating hormone restores bone volume, microarchitecture, and strength in aged ovariectomized rats.

We show the systemic administration of low levels of TSH increases bone volume and improves bone microarchitecture and strength in aged OVX rats. TSH's actions are mediated by its inhibitory effects on RANKL-induced osteoclast formation and bone resorption coupled with stimulatory effects on osteoblast differentiation and bone formation, suggesting TSH directly affects bone remodeling in vivo. INTRODUCTION: Thyroid-stimulating hormone (TSH) receptor haploinsufficient mice with normal circulating thyroid hormone levels have reduced bone mass, suggesting that TSH directly affects bone remodeling. We examined whether systemic TSH administration restored bone volume in aged ovariectomized (OVX) rats and influenced osteoclast formation and osteoblast differentiation in vitro. MATERIALS AND METHODS: Sprague-Dawley rats were OVX at 6 months, and TSH therapy was started immediately after surgery (prevention mode; n = 80) or 7 mo later (restoration mode; n = 152). Hind limbs and lumbar spine BMD was measured at 2- or 4-wk intervals in vivo and ex vivo on termination at 8-16 wk. Long bones were subjected to microCT, histomorphometric, and biomechanical analyses. The direct effect of TSH was examined in osteoclast and osteoblast progenitor cultures and established rat osteosarcoma-derived osteoblastic cells. Data were analyzed by ANOVA Dunnett test. RESULTS: In the prevention mode, low doses (0.1 and 0.3 microg) of native rat TSH prevented the progressive bone loss, and importantly, did not increase serum triiodothyroxine (T3) and thyroxine (T4) levels in aged OVX rats. In restoration mode, animals receiving 0.1 and 0.3 microg TSH had increased BMD (10-11%), trabecular bone volume (100-130%), trabecular number (25-40%), trabecular thickness (45-60%), cortical thickness (5-16%), mineral apposition and bone formation rate (200-300%), and enhanced mechanical strength of the femur (51-60%) compared with control OVX rats. In vitro studies suggest that TSH's action is mediated by its inhibitory effects on RANKL-induced osteoclast formation, as shown in hematopoietic stem cells cultivated from TSH-treated OVX rats. TSH also stimulates osteoblast differentiation, as shown by effects on alkaline phosphatase activity, osteocalcin expression, and mineralization rate. CONCLUSIONS: These results show for the first time that systemically administered TSH prevents bone loss and restores bone mass in aged OVX rats through both antiresorptive and anabolic effects on bone remodeling.