Integration of a formalized handoff system into the surgical curriculum: resident perspectives and early results.

HYPOTHESIS: The Situation, Background, Assessment, and Recommendation model (SBAR) provides an excellent framework for communication in daily resident handoffs. OBJECTIVE: To evaluate implementation of SBAR into the surgical curriculum. DESIGN: A curriculum using video and role-play scenarios to augment a didactic lecture on SBAR was implemented for general surgery residents. Resident assessment was achieved via an anonymous survey administered after training. Outcome was evaluated by assessing sentinel events and resident order entry 30 days before and after training. Surgical subspecialty resident order entries were used as controls. Duplicated, cancelled, and wrong patient orders were attributed to failed communication. SETTING: Academic department of surgery. PARTICIPANTS: Forty-five general surgery residents at our institution. RESULTS: Survey response rate was 100%. Poor communication was identified as the leading cause of handoff failure, with nurse-to-resident handoffs considered the most problematic. Overall, the curriculum was well received. Outcomes analysis demonstrated no difference in sentinel events. A 2.3% decrease in pretraining and posttraining order entry errors (14.5% vs 12.2%; P = .003) was demonstrated. No difference was demonstrated in controls who did not undergo SBAR training (12.9% vs 13.6%; P = .47). CONCLUSIONS: Most of the residents indicate that the SBAR curriculum addressed frequently encountered communication issues and taught clinically beneficial communication skills. The identified specific communication deficiencies will direct future curriculum goals. The SBAR model is an effective and valuable tool to standardize communication. Early outcomes analysis demonstrates a decrease in order entry errors after training. Sentinel events are infrequent and will require long-term evaluation.

Laparoscopic antrectomy for the treatment of type I gastric carcinoid tumors.

BACKGROUND: While the optimal treatment for type I gastric carcinoid tumors remains controversial, there is evidence to suggest that in multifocal disease, antrectomy may not only control local disease but also may lead to enterochromaffin-like cell (ECL) hyperplasia regression compared to medical and endoscopic treatments. MATERIALS AND METHODS: A single institution retrospective review of eight consecutive patients with multifocal type I gastric carcinoid tumor patients with no evidence of metastatic disease was performed from 2005 to 2006. All of these patients underwent laparoscopic antrectomy with Billroth II reconstruction. Patients' preoperative gastrin, chromogranin A levels, and biopsy and surgical specimen slides were compared with postoperative laboratory and biopsy slides. Pathology slides were reanalyzed by a blinded pathologist from our institution for evidence of tumor and ECL hyperplasia regression. RESULTS: All patients tolerated the procedure well with no reoperations or mortalities. Six of eight patient complained of mild reflux which was treated medically. One of eight had a mild wound infection which resolved with a course of cephalexin. Gastrin levels significantly decreased (98.9%) in all patients (P = 0.001). Furthermore, chromogranin A levels also significantly decreased (81.4%). Eight of eight patients showed no evidence of carcinoid tumor after surgery at mean biopsy follow-up of 17 mo (range 2-35 mo), however there was ECL hyperplasia after resection. Four of eight patients (50%) showed regression of ECL hyperplasia on postop biopsy, while the remaining four of eight showed no evidence of regression. CONCLUSIONS: This is the largest case series to investigate the surgical, clinical, and histologic outcomes of laparoscopic antrectomy in type I gastric carcinoid. Our data suggest that laparoscopic antrectomy is a safe and minimally invasive approach to treat nonmetastatic type I gastric carcinoid. All patients had no evidence of gross or microscopic disease at follow-up biopsy and almost half had regression of ECL hyperplasia at follow-up suggesting that antrectomy may be sufficient to prevent tumor recurrence. However, continued regular endoscopic surveillance and medical follow-up of patients with ECL hyperplasia are recommended.

Factors that predict outcome of abdominal operations in patients with advanced cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis have an increased risk of complications during surgery that is relative to the severity of liver disease; it is a challenge to determine which patients are the best candidates for surgery. We performed a hospital-based study to identify factors that might facilitate selection of operative candidates and guide their management. METHODS: A retrospective review was performed of 100 cirrhotic patients (50 classified as Child-Turcotte-Pugh [CTP] A, 33 as CTP B, and 17 as CTP C) who underwent abdominal surgery at an institution specializing in liver medicine and transplant from 2002-2008. Significant univariate variables were evaluated by multivariate logistic regression models to identify factors that correlate with outcome. RESULTS: The overall, 30-day postoperative mortality rate was 7%. The mortality for patients who were CTP A was 2%, CTP B was 12%, and CTP C was 12%; 33 patients had a Model for End-Stage Liver Disease (MELD) score >or=15, with 29% mortality. On the basis of multivariate analyses, risk factors for adverse outcome were American Society of Anesthesiologists (ASA) score >3; procedures being emergent; intraoperative blood transfusion; intraoperative blood loss >150 mL; presence of ascites; total bilirubin level >1.5 mg/dL; and albumin level <3 mg/dL. Addition of serum albumin to MELD score showed that patients with MELD score >or=15 and albumin 2.5 mg/dL) had significantly increased mortality (60% vs 14%, P < .01) and independently increased probability of adverse outcome (odds ratio, 8.4; P = .015). CONCLUSIONS: For patients with MELD scores >or=15, the preoperative albumin level correlates with outcome and could guide operative decisions. Intraoperative packed red blood cell transfusion correlates with adverse outcome and should be limited.

Current recommendations on diagnosis and management of right-sided diverticulitis.

We present the case of a 52-year-old female with recurrent symptomatic ascending colon diverticulitis who ultimately underwent elective laparoscopic right hemicolectomy. The following is a case report and literature review pertaining to right colonic diverticular disease.

Management of hernias in pregnancy.

BACKGROUND: Even though groin and umbilical hernias are rare in adult women, the rarer cases of pregnant women presenting with hernias create distinct challenges to treatment planning. The course of hernias in pregnant women, the effect of hernias on delivery, and the timing of elective herniorrhaphy have not been established. To date, there have been no published series establishing that postpartum repair of umbilical and groin hernias that develop in pregnancy is safe and acceptable. STUDY DESIGN: From September 2004 to July 2006, 12 female patients with groin or umbilical hernias occurring during pregnancy presented to a single surgeon at the Mount Sinai Medical Center. All patients later underwent postpartum herniorrhaphy and were enrolled retrospectively. All patients underwent either open umbilical or inguinal hernia repair primarily or using a plug-and-patch method (Bard Mesh PerFix Plug; Davol) in an ambulatory setting. Mean longterm followup was 17 months. RESULTS: Mean age of the patients was 35 years (range 27 to 41 years). The most common type of hernia was inguinal (58%). The predominant side was right (86%). None of the patients had an associated diagnosis or clinically significant medical history. All patients were evaluated, operated, and followed up by the same surgeon. Neither incarceration nor strangulation occurred in any patient before or after delivery. None required hospitalization or emergent hernia repair. Patients did not experience any delivery complications. All patients underwent elective postpartum open hernia repair with sedation and local anesthesia (4 to 52 weeks postpartum; mean 22 weeks postpartum). No patient experienced any perioperative or postoperative complications. None of the patients experienced a hernia recurrence. Four patients had subsequent uncomplicated pregnancies. CONCLUSIONS: This series lends support to the "watchful waiting" strategy during pregnancy, with a plan for postpartum herniorrhaphy. Elective, postpartum hernia repair provides similar results to the nonpregnant population.

Recurrence after laparoscopic ventral hernia repair: a prospective pilot study of suture versus tack fixation.

Mesh fixation in laparoscopic ventral hernia repair requires the use of tacks and/or permanent transabdominal sutures. Sutures pass through all fascial and muscle layers of the anterior abdominal wall, whereas tacks secure the mesh simply to peritoneum. Controversy exists regarding the optimal fixation method. In this pilot study, we compared recurrence rates between these two techniques. Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively and nonrandomly enrolled in the study and underwent either suture-fixation or tack-fixation. Office charts, computed tomography, and telephone interviews were used to determine recurrence events. chi2 and Student's t tests were performed to compare group characteristics and multivariate Cox regression analysis was used to assess for recurrence predictors after adjusting for potential confounders. From 2004 to 2005, 27 patients had suture repairs and 21 had tack repairs. The two groups had similar demographic, history, and operative variables. At a mean follow-up of 18 months, the recurrence rate was 14 per cent. In multivariate analyses, fixation method did not significantly affect recurrence. In this pilot study, patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experienced similar recurrence rates. Future studies will be needed to validate these findings.

Postoperative pain after laparoscopic ventral hernia repair: a prospective comparison of sutures versus tacks.

BACKGROUND AND OBJECTIVES: Mesh fixation in laparoscopic ventral hernia repair typically involves the use of tacks, transabdominal permanent sutures, or both of these. We compared postoperative pain after repair with either of these 2 methods. METHODS: Patients undergoing laparoscopic ventral hernia repair at the Mount Sinai Medical Center were prospectively enrolled in the study. They were sorted into 2 groups (1) those undergoing hernia repairs consisting primarily of transabdominal suture fixation and (2) those undergoing hernia repairs consisting primarily of tack fixation. The patients were not randomized. The technique of surgical repair was based on surgeon preference. A telephone survey was used to follow-up at 1 week, 1 month, and 2 months postoperatively. RESULTS: From 2004 through 2005, 50 patients were enrolled in the study. Twenty-nine had hernia repair primarily with transabdominal sutures, and 21 had repair primarily with tacks. Both groups had similar average age, BMI, hernia defect size, operative time, and postoperative length of stay. Pain scores at 1 week, 1 month, and 2 months were similar. Both groups also had similar times to return to work and need for narcotic pain medication. CONCLUSIONS: Patients undergoing laparoscopic ventral hernia repair with primarily transabdominal sutures or tacks experience similar postoperative pain. The choice of either of these fixation methods during surgery should not be based on risk of postoperative pain.

Non-physician practitioners' overall enhancement to a surgical resident's experience.

PURPOSE: The Mount Sinai Surgical Residency program uses physician assistants and nurse practitioners, jointly termed non-physician practitioners (NPPs), to adhere to the 80-hour work-week restrictions implemented by Accreditation Council of Graduate Medical Education (ACGME) resident duty hour requirements initiated in 2003. A survey was performed to determine how the integration of NPPs into the surgical subspecialty teams has affected surgical residents' perceptions of their education and overall residency experience. We review the roles of NPPs within surgical specialty teams as well as our survey findings about NPP and resident impressions about the NPP role. METHODS: A survey was distributed to every surgical resident and inpatient NPP using a Likert scale for responses. The survey addressed general experiences about the NPP-resident relationship in regard to education, continuity of care, workload, communication, collaboration, role, and hierarchy. NPP responses were compared with resident responses through a Pearson chi-square test. RESULTS: Sixty-six residents and 28 NPP responses were obtained. Overall, NPPs and residents have similar perceptions about the NPP function. Most NPPs and residents believe that having an NPP on the service decreases their workload (96.4% and 84.8%, respectively), and they believe that adequate communication and collaboration occurs between the NPPs and the residents (85.7% and 73.8% and 67.9% and 80.3%, respectively). Significantly more NPPs than residents feel that NPPs contribute to the residents' clinical education (75.0% vs 38.5%, p = 0.005) and that NPPs provide better continuity of care (96.4% vs 60.6%, p = 0.002). Although NPPs and residents believe that the NPP role is clearly defined, NPPs and residents have very different perceptions about where NPPs fall within the surgical hierarchy. Seventy-five percent of NPPs believe that they function at a senior resident level or above, whereas 90.5% of residents believe that NPPs function at the intern level or below (p < 0.001). CONCLUSIONS: We found that at our institution, residents and NPPs agree that they work well together and that NPPs positively contribute to resident education. We recommend a service-specific orientation for the residents with each rotation to clarify NPP responsibilities and functions, thereby maximizing collaboration. With a firm understanding of the various roles of the NPPs, a cohesive, multidisciplinary group can be attained while enhancing surgical education.

Cryptosporidiosis presenting as acute appendicitis: a case report.

Although uncommon in the United States, cryptosporidiosis can be life-threatening in an immunosuppressed host. Rarely, an acute infection of this gastrointestinal illness can present as another disease entity. We present only the third reported case of cryptosporidial infection presenting as acute appendicitis in a 17-year-old HIV+ patient.

Outcome of renal transplants from pediatric donors <5 yr of age.

AIM: Outcomes of single renal transplants from donors <5 yr old have traditionally been inferior to those from older donors. We retrospectively studied our experience with patients who received renal transplants, either individually or en bloc, from young donors (<5 yr of age) to determine the utility of these organs. We also compared the outcomes of these transplant patients maintained on either cyclosporine- (CyA) or tacrolimus-based (TRL) immunosuppression regimens. PATIENTS: Ninety-eight patients received transplants at our center from donors <5 yr of age between August 1993 and August 2003. They were followed-up from 12 months to 11 yr. Patients were divided into four groups based on whether they received single or en bloc transplants, and whether CyA or TRL was the base immunosuppressive agent. Patients in group I (n = 13) received single pediatric kidneys and were treated with CyA regimens; group II patients (n = 26) also received single pediatric kidneys, but were treated with TRL regimens; group III patients (n = 31) were transplanted en bloc and were treated with CyA; and group IV patients (n = 28) received en bloc transplants and were treated with TRL. RESULTS: One-year patient and death-censored graft survival was not significantly different between recipients of en bloc vs. single grafts (i.e. 88 and 85% vs. 90 and 87%, respectively), or between the four treatment groups (group I: 85 and 85%, group II: 92 and 88%, group III: 87 and 84%, and group IV: 89 and 86%, respectively). The overall 1-yr rejection rate was 30% (29 of 98), which was significantly higher in the CyA-treated patients 19 of 44; i.e. 43%, than in TRL-treated patients 10 of 54, i.e. 19%, p = 0.03). In the en bloc recipients, seven grafts (12%) were lost as a result of vascular thrombosis. Notably, none of the single kidneys were lost because of vascular thrombosis. At the end of follow-up the creatinine levels of both groups were comparable. CONCLUSIONS: Pediatric donor kidneys transplanted individually provide for equal patient and graft survival when compared with en bloc transplants. TRL can be used reduce the detrimental effect of acute rejection on graft growth and function when compared with CyA. Single use of such kidneys can safely and efficaciously be transplanted into adult recipients, greatly expanding the donor pool.