Adapting Surgical Clerkship Curricula in Response to the COVID-19 Pandemic.

BACKGROUND: Coronavirus disease-19 (COVID-19) impacted medical education and led to the significant modification or suspension of clinical clerkships and rotations. OBJECTIVES: To describe a revised surgery clerkship curriculum, in which we divided in-person clinical teaching into smaller groups of students and adopted online-based learning to foster student and patient safety while upholding program standards. METHODS: The third-year surgery core clerkship of a 4-year international English-language program at the Medical School for International Health at Ben Gurion University of the Negev, Beer Sheva, Israel, was adapted by dividing students into smaller capsules for in-person learning and incorporating online learning tools. Specifically, students were divided evenly throughout three surgical departments, each of which followed a different clinical schedule. RESULTS: National Board of Medical Examiners clerkship scores of third-year medical students who were returning to in-person clinical clerkships after transitioning from 8 weeks of online-based learning showed no significant difference from the previous 2 years. CONCLUSIONS: To manage with the restrictions caused by COVID-19 pandemic, we designed an alternative approach to a traditional surgical clerkship that minimized the risk of exposure and used online learning tools to navigate scheduling challenges. This curriculum enabled students to complete their clinical rotation objectives and outcomes while maintaining program standards. Furthermore, this approach provided a number of benefits, which medical schools should consider adopting the model into practice even in a post-pandemic setting.

Peach pit impaction presenting as gallstone ileus.

Small bowel obstruction (SBO) secondary to fruit pit impaction is rare. The presence of an ovoid, stony body in the bowel lumen on radiologic imaging in a patient presenting with signs and symptoms of SBO is likely to raise concern for gallstone ileus. We report the case of a 56-year-old man who presented with a 1-day history of intermittent left-sided abdominal pain and nausea associated with a single episode of vomiting. CT scan of the abdomen and pelvis revealed a 3.3 cm impacted stony mass in the terminal ileum resulting in high-grade partial SBO. The mass had a hypodense centre encased within a hyperdense, ridged outer layer. The diagnostic impression was gallstone ileus. The object was removed via enterotomy and was found to be a peach pit.

Diagnosis and Management of Perforated Duodenal Ulcers following Roux-En-Y Gastric Bypass: A Report of Two Cases and a Review of the Literature.

Perforated duodenal ulcers are rare complications seen after roux-en-Y gastric bypass (RYGP). They often present as a diagnostic dilemma as they rarely present with pneumoperitoneum on radiologic evaluation. There is no consensus as to the pathophysiology of these ulcers; however expeditious treatment is necessary. We present two patients with perforated duodenal ulcers and a distant history of RYGP who were successfully treated. Their individual surgical management is discussed as well as a literature review. We conclude that, in patients who present with acute abdominal pain and a history of RYGB, perforated ulcer needs to be very high in the differential diagnosis even in the absence of pneumoperitoneum. In these patients an early surgical exploration is paramount to help diagnose and treat these patients.

Early results of trans-oral endoscopic plication and revision of the gastric pouch and stoma following Roux-en-Y gastric bypass surgery.

OBJECTIVE: A new technique for endoscopic plication and revision of the gastric pouch (EPRGP) for patients who underwent gastric bypass (RGB) surgery was evaluated in patients with severe GERD, dumping syndrome, failure of weight loss, or all of these. PATIENTS AND METHODS: Patients underwent EPRGP over a 12-month period. The StomaphyX device (Endogastric Solutions, Redmond, WA) was utilized over a standard flexible gastroscope. Patients were kept on a liquid diet for 1 week. RESULTS: The study included 64 patients with a mean age of 48 years who underwent 67 procedures. EPRGP was performed an average of 5 years after RGB. The mean preoperative BMI was 39.5 kg/m². The primary indications for the procedure were inadequate weight loss, dumping syndrome (42), and GERD (15). The mean follow-up period was 5.8 months (range, 3 to 12). The average operative time was 50 minutes, with a significant reduction with increased operator experience. There were only 2 (3%) intraoperative complications during the early period (equipment failure), which did not result in any morbidity. All symptoms from dumping syndrome or reflux improved, with no further operative-related complications. The mean weight loss was 7.3 kg. CONCLUSIONS: This study demonstrates the technical feasibility, safety, and efficacy of EPRGP.

Heterotopic mesenteric ossification following gastric bypass surgery: case series and review of literature.

Heterotopic mesenteric ossification (HMO) is a rare entity with few cases reported in the world literature. We report two cases. Both patients underwent an open gastric bypass with Roux-en-Y reconstruction procedure for morbid obesity and subsequently presented with gastrointestinal fistulae associated with HMO.

Endoscopic gastric pouch plication - a novel endoluminal incision free approach to revisional bariatric surgery.

10-40% of Roux-en-Y gastric bypass (RYGB) patients regain significant weight after Roux-en-Y gastric bypass surgery due to dilation of the pouch and/or the gastrojejunal (GJ) anastomosis. Traditional revision surgery is associated with significant morbidity (e.g. post-anastomotic GJ leak) where less invasive endoluminal procedures may represent safer alternatives. The present article reports a case of the safe and successful use of endoluminal gastric pouch plication (EGPP) using the StomaphyX™ device to correct both a dilated gastric pouch and a dilated gastrojejunostomy in a post-RYGB patient who regained significant weight.

Transoral incision free fundoplication (TIF) - A new paradigm in the surgical treatment of GERD.

An estimated 10 billion dollars is spent treating gastro-oesophageal reflux disease (GERD) in the USA every year. The present article reports a case of the safe and successful use of transoral incisionless fundoplication (TIF) using the EsophyX90™ device in the surgical treatment of GERD.

The incidence of pulmonary embolism in open versus laparoscopic gastric bypass.

Obesity independently increases the risk of pulmonary embolism (PE). We compare a superobese population (body mass index [BMI] > 55 kg/m(2)) undergoing open gastric bypasses (OGBs) with a similarly matched group of laparoscopic gastric bypasses (LGB) to see if the incidence of PE differs. We included all patients undergoing OGB (n = 193, average BMI = 51 kg/m(2)) at our institution by a single surgeon between July 1999 and April 2001. Thirty-one patients were superobese (BMI > 55 kg/m(2)). LGB was started at our institution in April 2001. Since that time 213 patients (average BMI = 52 kg/m(2)) have undergone the procedure. One hundred and nine patients were superobese. Pre- and postoperative prophylaxis included sequential compression stockings and subcutaneous heparin. Postoperatively, patients who developed signs of hypoxia, tachypnea, or tachycardia underwent a chest X-ray and spiral computed tomography. In addition, all patients who expired in the 30-day postoperative period underwent postmortem examination. Data were analyzed using the chi-squared test. In the OGB group, four patients (2.1%) developed PE. All occurred in superobese patients with a BMI > 55 kg/m(2). Three were fatal PEs and one was nonfatal. None of these patients had a prior history of deep vein thrombosis, PE, venous stasis disease, or pulmonary hypertension. In the LGB group, one patient (0.9%) had a nonfatal PE. This patient had a history of deep vein thrombosis. The incidence of PE was statistically higher in the superobese OGB group (P < 0.01). Despite the theoretical hindrance to venous return and vena caval compression observed with pneumoperitoneum, fewer PEs occurred in the laparoscopic group. Our data, however, suggest that patients with a BMI > 55 kg/m(2) might be at an increased risk for PE independent of operative approach.

Insulin-sensitizing effects of thiazolidinediones are not linked to adiponectin receptor expression in human fat or muscle.

Circulating adiponectin levels are increased by the thiazolidinedione (TZD) class of PPARgamma agonists in concert with their insulin-sensitizing effects. Two receptors for adiponectin (AdipoR1 and AdipoR2) are widely expressed in many tissues, but their physiological significance to human insulin resistance remains to be fully elucidated. We examined the expression patterns of AdipoR1 and AdipoR2 in fat and skeletal muscle of human subjects, their relationship to insulin action, and whether they are regulated by TZDs. Expression patterns of both AdipoRs were similar in subcutaneous and omental fat depots, with higher expression in adipocytes than in stromal cells and macrophages. To determine the effects of TZDs on AdipoR expression, subcutaneous fat and quadriceps muscle were biopsied in 14 insulin-resistant subjects with type 2 diabetes mellitus after 45 mg pioglitazone or placebo for 21 days. This duration of pioglitazone improved insulin's suppression of glucose production by 41% and enhanced stimulation of glucose uptake by 27% in concert with increased gene expression and plasma levels of adiponectin. Pioglitazone did not affect AdipoR expression in muscle, whole fat, or cellular adipose fractions, and receptor expression did not correlate with baseline or TZD-enhanced insulin action. In summary, both adiponectin receptors are expressed in cellular fractions of human fat, particularly adipocytes. TZD administration for sufficient duration to improve insulin action and increase adiponectin levels did not affect expression of AdipoR1 or AdipoR2. Although TZDs probably exert many of their effects via adiponectin, changes in these receptors do not appear to be necessary for their insulin-sensitizing effects.

Does the position of the alimentary limb in Roux-en-Y gastric bypass surgery make a difference?

Intestinal obstruction and other complications have been reported following Roux-en-Y gastric bypass (RYGB) surgery. There is controversy of whether the alimentary limb should be placed in the retrocolic or antecolic position. A retrospective analysis was performed on 444 patients undergoing RYGB surgery for morbid obesity during a six year period. During operation, the surgeon chose the positioning of the 75-cm alimentary limb based upon technical consideration (the presence of adhesions from prior surgical procedures, thickness of the transverse mesocolon and mobility of the small bowel mesentery). Group A (216) patients had placement of the Roux limb anterior to the transverse colon, and group B (228) patients had placement of the limb through an opening created in the transverse mesocolon. The average age was 40 years (range 19-64) and the body mass index ranged from 40 to 75 kg/m2. Patients were followed for 24-86 months (mean 36 months). Any patients lost to follow-up were excluded. The average age of patients in the study was 40 years (range 19-64 years). Patients in both groups were similar in their body mass index and demographic characteristics. Group A had 16 patients (7.4%) that had early intolerance to enteral intake, compared to 13 patients in group B (5.7%, P>0.05). Thirteen patients required reoperation for intestinal obstruction (seven patients in group A and six patients in group B (P>0.05). Development of anastomotic stricture occurred in one patient (0.5%) in group A and three patients (1%, P>0.05) in group B. There were no differences in mean operating room times, hospital length of stay, and excess weight lost. No other complications during the follow-up period were attributed to the position of the alimentary limb. Placement of the Roux limb in the antecolic position is may be technically more feasible in some patients and does not appear to be associated with more complications. It avoids the risk of an internal hernia through the transverse and does not appear to be associated with feeding difficulties in the early or late postoperative period.

Experience with inferior vena cava filter placement in patients undergoing open gastric bypass procedures.

OBJECTIVE: Patients undergoing open gastric bypass (OGB) for morbid obesity are at significant risk for pulmonary embolism (PE) despite the use of subcutaneous heparin injections and sequential compression devices. Prophylactic preoperative inferior vena cava (IVC) filter placement may reduce this risk. We report our experience with simultaneous IVC filter placement and OGB in an operating room setting. METHODS: From July 1999 to April 2001, 193 patients (group 1) underwent OGB. Eight patients had prophylactic intraoperative IVC filters placed for deep vein thrombosis, PE, or pulmonary hypertension. From May 2001 to January 2003, 181 patients (group 2) underwent OGB. There were 33 IVC filters placed for body mass index (BMI) greater than 55 kg/m2 in addition to the above-mentioned criteria. To confirm observations made in group 1 and 2 patients, from July 2003 to May 2005, 197 patients (group 3) underwent OGB, and patients with a BMI greater than 55 kg/m2 (n = 35) were offered IVC filter placement. Group 3A (n = 17) consented to IVC filter placement, and group 3B (n = 18) did not. RESULTS: Fifty-eight IVC filters were placed (100% technical success rate) with an increase in operating room time of 20 +/- 5 minutes. In group 1, the eight patients with IVC filters had a BMI greater than 55 kg/m2. There were four PEs (3 fatal and 1 nonfatal) in the other 185 patients, all which occurred in patients with BMIs greater than 55 kg/m2. In group 2, there were no PEs. The perioperative PE rate in these patients was reduced from 13% (4/31; 95% confidence interval [CI], 1.1%-25.7%) to 0% (0/33; 95% CI, 0%-8.7%). Perioperative mortality was reduced from 10% (3/31; 95% CI, 0%-20.0%) to 0% (0/33; 95% CI, 0%-8.7%). There were no pulmonary emboli or deaths related to PE in group 3A patients. Group 3B patients had a 28% PE rate (two fatal and three nonfatal) and an 11% PE-related death rate. None of the remaining patients in group 3 had a PE. CONCLUSIONS: Intraoperative IVC filter placement for the prevention of PE in morbidly obese patients undergoing OGB is feasible. We observed a significant reduction in the perioperative PE rate when a BMI greater than 55 kg/m2 was used as an indication for IVC filter placement despite the use of subcutaneous heparin injections and sequential compression devices.

Gastric bypass in a low-income, inner-city population: eating disturbances and weight loss.

OBJECTIVE: To examine the prevalence of eating disturbances and psychiatric disorders among extremely obese patients before and after gastric bypass surgery and to examine the relationship between these disturbances and weight outcomes. RESEARCH METHODS AND PROCEDURES: Sixty-five women patients (ages 19 to 67) with a mean BMI of 54.1 were assessed by semistructured psychiatric interview before surgery and by telephone interview after surgery (mean follow-up: 16.4 months) to determine psychiatric status, eating disturbances, and weight and health-related variables. RESULTS: Patients lost a mean of 71% of their excess BMI, with significantly poorer weight loss outcomes among African Americans. Psychiatric disorders remained prevalent before (37%) and after (41%) surgery. In contrast, binge eating disorder dropped from 48% to 0%. Psychiatric diagnosis did not affect weight outcomes. Instead, more frequent preoperative binge eating, along with greater initial BMI, follow-up length, and postoperative exercise, predicted greater BMI loss. Postsurgical health behaviors (exercise and smoking) and nocturnal eating episodes were also linked to weight loss. Exercise frequency increased and smoking frequency tended to decrease after surgery. DISCUSSION: These findings indicated that eating and psychiatric disturbances did not inhibit weight loss after gastric bypass and should not contraindicate surgery. Prior binge eating, eliminated after surgery, predicted BMI loss and, thus, may have previously been a maintaining factor in the obesity of these patients. The association between health behaviors and outcome suggests possible targets for intervention to improve surgical results. Poorer outcomes among African Americans indicate that these patients should be closely monitored and supported after surgery.

Intussusception: an uncommon cause of postoperative small bowel obstruction after gastric bypass.

Intussusception of the jejuno-jejunal anastomosis is a rare complication of the Roux-en-Y gastric bypass (RYGBP). There are only 3 previous cases reported in the surgical literature. We describe 2 adults who developed jejuno-jejunal intussusception requiring emergent laparotomy several months after RYGBP. Both patients underwent exploratory laparotomy after the diagnosis was made with abdominal CT scan. Each patient had an uneventful postoperative course after bowel resection and revision of the enteroenterostomy. Small bowel obstruction due to intussusception may occur many months after RYGBP and may present with non-specific symptoms such as crampy abdominal pain, nausea, and vomiting. The diagnosis of this rare entity is typically made via abdominal CT scan. Treatment mandates urgent abdominal exploration with reduction.

Critical care of the obese and bariatric surgical patient.

Obesity is associated with a chronic inflammatory state that predisposes to atherogenesis, thrombogenesis, and carcinogenesis and may increase susceptibility to infections. Critically ill, obese patients have higher mortality. MOF is the best predictor of ICU mortality for obese patients. Pulmonary hypertension and higher BMI are associated with higher surgical risk. Progress in surgical technique and anesthesia has substantially improved the safety of performing operations in severely obese patients.