Barriers to implementation of the FUSE program.

INTRODUCTION: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed The Fundamental Use of Surgical Energy (FUSE) Program to promote safe use of energy devices in the operating room and endoscopy suite. Utilization of the program has been slower than anticipated. This study aims to determine the barriers to implementing FUSE. METHODS: An anonymous survey was distributed to a surgery department at an academic teaching hospital (n = 256). Participants indicated their level of training. Answers were measured using a 5-point Likert scale. RESULTS: There were 94 (36.7%) respondents to the survey from September 7 to 20, 2016. Fifteen surveys were incomplete, leaving 79 responses for analysis. Most respondents were at the faculty level (45/79, 57.0%). The majority had heard of FUSE (62/79, 78.5%), but only 19 had completed the certification (19/62, 32.3%). There was no difference in the completion rate between faculty and trainees (26.7 vs. 20.6%, OR 1.4, 95% CI 0.49-4.06, p = 0.53). The most common reasons for not taking the exam were lack of time to study (26/43, 60.5%) and lack of time to take the exam (28/43, 62.1%); however, cost was not a barrier (12/43, 27.9%). The majority identified a personal learning gap regarding the safe use of surgical energy (30/43, 69.7%). Of the 19 FUSE-certified respondents, reasons cited for completing the exam included wanting to prevent adverse events to patients and in the operating room (17/19, 89.5% and 17/19, 89.5%), and the belief that the course would make them a safer surgeon (16/19, 84.2%). CONCLUSIONS: FUSE teaches the proper use of radiofrequency energy, how to prevent unnecessary injury, and promotes safe practice. Close to three out of every four surgeons self-identified a personal knowledge gap regarding the safe use of surgical energy. Time restraints were cited most commonly as the barrier to starting and completing FUSE. Integrating the FUSE program into resident educational conferences, faculty grand rounds, or national conferences may help improve participation and drive adoption of FUSE certification.

Mesenchymal stem cell therapy to promote limb transplant functional recovery.

BACKGROUND: Limb transplantation is a viable option for reconstruction after traumatic limb loss; however, functional recovery can be suboptimal. The aim of this study was to determine whether mesenchymal stem cell (MSC) administration can improve limb transplant functional recovery. METHODS: Orthotopic syngeneic hindlimb transplants were performed in Lewis rats, followed by topical and intravenous injections of syngeneic MSCs (5 × 106 ) or vehicle. Transplanted limb sensory and motor functions were tested by cutaneous pain reaction and walking track analysis, respectively. RESULTS: MSCs expanded ex vivo were CD29+ , CD31- , CD34- , CD44+ , CD45low , CD90+ , MHC Class-I+ , Class-II- , and pluripotent. Greater than 90% of limb transplants survived. At 4 weeks post-transplantation, the mean sensory nerve (tibial, peroneal, or sural) function in MSC (n = 9) and vehicle (n = 9) groups was <0.3 on a scale of Grades 0-3 (0 = No function; 3 = Normal). By 8 weeks, the sensory scores for tibial, peroneal, and sural nerves were 2.2 ± 0.7, 1.2 ± 0.5, and 1.7 ± 0.9 in the vehicle, and 2.6 ± 0.4, 1.0 ± 0.9, and 1.7 ± 0.9 in the MSC group, respectively (n = 9/group). At 4, 8, 16, and 24 weeks, the overall sensory function was higher in MSC group (≥7/group). Sciatic Function Index (SFI), a measure of motor function, could not be calculated because of poor foot prints; therefore, a novel grading system was developed. Bone fusion/vascularization as determined by X-ray films/laser Doppler (≥2 week post-transplantation) were normal (n = 3/group). Gastrocnemius muscle was atrophied (P < 0.05), and flexion contractures were evident by 24 weeks. CONCLUSIONS: Bone marrow-derived MSC therapy appears to improve sensory function recovery in a rat limb transplant model. Published 2016. This article is a U.S. Government work and is in the public domain in the USA Microsurgery 37:222-234, 2017.

Predictors of appendiceal perforation in an equal access system.

BACKGROUND: Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. MATERIALS AND METHODS: All patients undergoing appendectomy for acute appendicitis (November 2004-October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. RESULTS: A total of 680 patients (mean age 30±16 y; 37% female) were included. The majority were Caucasian (56.4% [n=384]; African Americans 5.6% [n=38]; Asians 1.9% [n=13]; and other 48.9% [n=245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P=0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P=0.273; 6.60% junior versus 5.50% senior enlisted, P=0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P=0.7). Only age had a correlation, with individuals aged 66-75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02-1.05; P<0.001). CONCLUSIONS: In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Pilonidal disease in a military population: how far have we really come?

BACKGROUND: Pilonidal disease (PD) has a long connection with military personnel, even nicknamed "jeep disease" during World War II. The aim of this study was to identify factors associated with recurrence and complications after surgery in a military population. METHODS: A retrospective cohort analysis of operative therapy for PD at a single institution from 2005 to 2011 was conducted. Patient demographics, disease characteristics, and surgical methods were assessed for the primary outcomes of recurrence and morbidity. RESULTS: A total of 151 patients with PD were identified, who underwent excision (45.7%), excision with primary closure (29.8%), and incision and drainage (9.9%). Overall recurrence and morbidity rates were 27.2% and 34.4%, respectively. Black race, chronic disease, wound infection, and infection and drainage were associated with recurrence (P < .05), and excision with primary closure was associated with increased complications (P < .001). CONCLUSIONS: PD remains a significant source of morbidity and recurrence among military personnel. Certain patient-related and disease-related factors portend a worse prognosis, with black race and operative method the strongest predictors of outcomes.

Pressure tolerance of newly constructed staple lines in sleeve gastrectomy and duodenal switch.

BACKGROUND: Many bariatric surgeons elect to pressure test the newly constructed staple lines in sleeve gastrectomy and duodenal switch procedures as a means of intraoperatively detecting leaks. The pressure tolerance of these fresh staple lines has not been well studied in a clinical setting. METHODS: This is a retrospective institutional review board-approved study that analyzed resected stomachs immediately after resection during a bariatric operation performed using sleeve gastrectomy or biliopancreatic diversion with duodenal switch. Resected stomachs were connected to a normal saline infusion and manometric pressure device for determining the maximum stomach capacity, the leak pressure, and the location of the first leak. RESULTS: Thirty patients (9 underwent biliopancreatic diversion with duodenal switch and 21 underwent sleeve gastrectomy) met the inclusion criteria (mean age of 44.7 years, 63.3% female) with a mean body mass index of 44.1 that was higher with biliopancreatic diversion (51.3 vs 41.0, P = .001) and a mean weight loss of 83 lb (a body mass index decrease of 13.4; median follow-up, 307 days). The leak volume of the resected stomach averaged 1,478 mL (range 1,100 to 2,200) with an average pressure of 25.6 cm H2O (range 12 to 60). The volume and leak pressures were equivalent despite the operative approach (P = .79 and .32, respectively), and there was no difference in the location of the leak (staple line or intrinsic stomach) based on volume or pressure (P = .246 and .131, respectively), with 50% of leaks occurring on the staple lines. CONCLUSIONS: The fresh staple lines in vertical sleeve gastrectomy and duodenal switch show burst strength well in excess of any intragastric pressures likely to be created by brief intraoperative leak checks via air instilled by an orogastric tube or intraoperative endoscopy. Leak testing is not likely to create iatrogenic damage to properly constructed fresh staple lines in these procedures.