Medical students in breast clinics--how welcome are they and how can we improve their learning opportunities?

OBJECTIVE: Clinical examination skills are an essential component of medical education, with students having the opportunity to practice important skills to facilitate their learning. The opportunities to practice intimate examinations, however, can be varied, with a number of patients declining to give consent, limiting the learning opportunities in clinic. This study aimed to identify whether patient demographics correlated with varying degrees of consent toward student participation. METHODS: A questionnaire was distributed to patients attending a surgical preassessment clinic with confirmed breast pathology regarding their attitudes toward different roles they were happy for students to have in their treatment journey. These results were analyzed using SPSS 20. RESULTS: Overall, 111 patients responded, aged between 17 and 86 years; 42 (38%) were under the care of a male surgeon. Patients under the care of a female surgeon were less likely to agree to students being in clinic (p = 0.009), take a history (p = 0.012), or examine them (p = 0.019). Increasing age was associated with increased agreement to being examined (p = 0.028), but there was no correlation between clinic attendance frequency and acceptance of students. CONCLUSIONS: Our findings suggest patients under the care of a male surgeon were more likely to consent to history taking and examination by students, though this may be owing to patient selection bias. Older patients were more likely to consent to being examined, though previous clinic attendance did not improve consent to medical students.

How does knowledge of three-dimensional excision margins following breast conservation surgery impact upon clinical target volume definition for partial-breast radiotherapy?

BACKGROUND AND PURPOSE: To compare partial-breast clinical target volumes generated using a standard 15 mm margin (CTV(standard)) with those generated using three-dimensional surgical excision margins (CTV(tailored 30)) in women who have undergone wide local excision (WLE) for breast cancer. MATERIAL AND METHODS: Thirty-five women underwent WLE with placement of clips in the anterior, deep and coronal excision cavity walls. Distances from tumour to each of six margins were measured microscopically. Tumour bed was defined on kV-CT images using clips. CTV(standard) was generated by adding a uniform three-dimensional 15 mm margin, and CTV(tailored 30) was generated by adding 30 mm minus the excision margin in three-dimensions. Concordance between CTV(standard) and CTV(tailored 30) was quantified using conformity (CoI), geographical-miss (GMI) and normal-tissue (NTI) indices. An external-beam partial-breast irradiation (PBI) plan was generated to cover 95% of CTV(standard) with the 95% isodose. Percentage-volume coverage of CTV(tailored 30) by the 95% isodose was measured. RESULTS: Median (range) coronal, superficial and deep excision margins were 15.0 (0.5-76.0)mm, 4.0 (0.0-60.0)mm and 4.0 (0.5-35.0)mm, respectively. Median CoI, GMI and NTI were 0.62, 0.16 and 0.20, respectively. Median coverage of CTV(tailored 30) by the PBI-plan was 97.7% (range 84.9-100.0%). CTV(tailored 30) was inadequately covered by the 95% isodose in 4/29 cases. In three cases, the excision margin in the direction of inadequate coverage was

Vertical banded gastroplasty: 6 years experience at a center in Poland.

BACKGROUND: Vertical banded gastroplasty (VBG) has been performed in our department as a restrictive operation for treatment of morbid obesity. We assessed efficacy, safety, and quality of life (QoL) after VBG, based on our 6-year experience. METHODS: 101 patients with >1 year follow-up who underwent VBG between January 1998 and May 2003, were retrospectively studied. Mean age was 41 years, and mean preoperative BMI was 51.3 kg/m2. Almost 60% of the patients suffered from hypertension, and 25% were diabetic. Postoperative QoL was determined with the BAROS questionnaire. Data concerning weight loss and co-morbidities were collected during the postoperative visits. RESULTS: 87.2% of patients achieved > or = 50% EWL. 86 patients (85.2%) responded to the BAROS questionnaire. >90% of the patients analyzed according to BAROS, reported improvement in QoL after VBG. No patient reported deterioration in health or well-being after the VBG. Anti-hypertensive medication was discontinued in 26 patients (56.5%) and decreased in the other 15 hypertensive patients (32.6%). 35% of diabetic patients did not require further treatment, while a further 40% had their insulin doses decreased or were switched to oral drugs. Early complications occurred in 4.65%, and consisted of an evisceration, pulmonary embolus and gastric leak. Late complications occurred in 20.9%, and included bleeding from peptic ulcer, incisional hernia, stomal stenosis and staple-line disruption (3.5%). There have been no deaths. CONCLUSION: VBG provided significant weight reduction and improved QoL in the vast majority of morbidly obese patients. Patients with diabetes and hypertension benefitted because these co-morbidities were improved or disappeared with the weight loss.

Successful treatment of gastric fistula following rhabdomyolysis after vertical banded gastroplasty.

Vertical banded gastroplasty is a gastric restrictive operation which has been performed with very satisfactory results in our department. We present a 46 year-old male with BMI 48, who experienced rhabdomyolsis after a VBG operation, complicated by perforation of an upper pouch ulcer and subsequent gastric fistula. Cardiac and renal failure occurred, necessitating intensive therapy with catecholamines, diuretics and hemodialysis. The patient underwent multiple operations, drainage of a retroperitoneal abscess, suture of a perforated ulcer, and gastric decompression by a gastrostomy. Prolonged treatment including TPN, drainage, broad spectrum antibiotics, skin and would protection and jejunostomy feeding, were necessary to obtain an eventual successful outcome. This case demonstrates that unexpected surgical complications may occur in morbidly obese patients and how difficult and long the management of these may be. Rhabdomyolsis is a potentially life-threatening complication of bariatric surgery, and careful postoperative observation of the patient is mandatory.

[Contemporary methods of the surgical treatment of nonspecific inflammatory bowel diseases]. / Wspólczesne poglady na chirurgiczne leczenie nieswoistych zapalnych chorób jelit.

Significant number of patients suffering from Crohn's disease (CD) and ulcerative colitis (UC) require surgical treatment on various stages of disease. Operative treatment of CD is usually indicated due to complications or ineffective medical treatment, but recurrence of disease and need for reoperation is common. Indications for surgical management in UC include complications (e.g. hemorrhage, perforation, toxic colitis) and prevention of late complications or neoplastic transformation. The role of surgery in the management of inflammatory bowel diseases has been confirmed thanks to recent development in operative techniques, advances in pathophysiology and introduction of laparoscopic methods, which result in improved life quality and better postoperative outcome. The paper presents indications for surgical treatment and practical aspects of operative techniques.

[Laparoscopic colorectal surgery--own experience]. / Laparoskopowe leczenie chorób jelita grubego--doswiadczenia wlasne.

The advent of laparoscopic colorectal surgery evoked discussion on its advantages and limitations. Although application of laparoscopy in the management of benign colorectal diseases has been widely accepted, its use for treatment of malignancies is still controversial. Many reports suggest that laparoscopic operations provide similar oncological radicality as open procedures, with less operative trauma, shorter hospital stay and low complication rate. In the hands of well-trained surgeon laparoscopic colorectal surgery seems to be attractive operative modality. Authors present own experience with laparoscopic colorectal surgery.

[Indications and contraindications for surgical treatment of morbid obesity--the choice of operative method]. / Wskazania i przeciwwskazania do chirurgicznego leczenia otylosci--wybór sposobu operacji.

Surgery for morbid obesity should be considered in case of failure of conservative treatment (diet, physical activity, psychotherapy, supportive medications). It is strongly recommended also for patients with significant concomitant diseases (e.g. cardiovascular, pulmonary etc) difficult to manage with traditional therapy. Patients' selection for surgery seems to be essential issue. Typical indications for surgical procedure include: BMI > 40 or BMI > 35 in patients with at least two obesity-related diseases, ineffective conservative treatment. Main contraindications are GI tract diseases (esophagitis, peptic ulcer), severe cardiovascular insufficiency, alcohol or drug abuse and mental disorders. There are two types of operative procedures currently performed restrictive and malabsorptive. The first group consists of following operations: 1) Silicon Ring Vertical Gastroplasty (SRVG), 2) Vertical Banded Gastroplasty (VBG), 3) Adjustable Silicon Gastric Banding (ASGB), 4) Non-Adjustable Gastric Banding (NGB). The latter group comprises: 1) Roux-Y Gastric By-Pass (RYGB) and 2) Bilipancreatic diversion. The paper describes complications, advantages and disadvantages for both groups of bariatric procedures and points out factors that should be considered in patients' selection for various types of operation.

[The impact of postoperative weight loss on concomitant obesity-related diseases]. / Ubytek masy ciala po chirurgicznym leczeniu otylosci i jego wplyw na choroby wspólistniejace z otyloscia.

Obesity-related diseases, especially diabetes mellitus and hypertension, have huge impact on mortality in obese patients. The aim of the study was the assessment of relationship between postoperative weight loss and further management of concomitant, obesity related diseases (hypertension and diabetes). The group of 106 patients who underwent restrictive procedures for morbid obesity at our department was retrospectively analyzed. Data were collected on follow-up visits according to designed questionnaires. Nine of thirty-two diabetic patients (28.13%) did not require any treatment after surgery, while in fourteen cases (43.75%) previous dosages of insulin were modified (reduced). Nine diabetic patients (28.13%) required the same treatment as before. Bariatric surgery had significant impact on patients with arterial hypertension. Antihypertensive drugs dose was reduced in 43.9% of patients, whereas 31.5% became normotensive in postoperative course (statistically significant). None of the operations appeared to be superior to others in terms of diabetes mellitus and hypertension control in postoperative course. Improvement in concomitant diseases management was markedly better for patients with lower preoperative BMI. Restrictive operations had positive impact on concomitant obesity-related diseases and cured about 30% of patients with preoperative diagnosis of diabetes or arterial hypertension.

Extrahepatic bile duct injury during laparoscopic cholecystectomy -- own material.

BACKGROUND: Despite recognised advantages of laparoscopy, the damage of extrahepatic bile ducts during cholecystectomy is a subject of ongoing discussions, as such injuries are more frequent comparing with open surgery. MATERIAL/METHODS: The analysis included 6873 patients who underwent laparoscopic cholecystectomy. The study group comprised both the patients after elective surgery due to symptomatic cholelithiasis and patients after emergency procedures necessitated by acute cholecystitis. RESULTS: Common bile duct was damaged in 9 patients. Five people had their main bile duct transected, in 2 people it was partial excision, and in the other 2 subjects - puncture damage with electrocoagulation took place. In seven cases, the damage was diagnosed still during laparoscopy and conversion to open surgery was performed. In two subjects the damage was diagnosed in postoperative period and it was subsequently confirmed by ERCP. Reconstructive surgery included: CBD suturing with interrupted stitches, end-to-end anastomosis over T-tube and Roux-en-Y bilioenteric anastomosis. Good postoperative outcome was obtained in 6 patients. One subject required repeated endoscopic dilatation and placement due to recurrent cholangitis. Two patients died due to upper gastrointestinal bleeding and multiple organ failure. CONCLUSIONS: Extrahepatic bile duct injury remains a dangerous complication following cholecystectomy. It is more likely to occur in case of anomalous anatomy of bile ducts, inflammatory or malignant infiltration and technical errors of an operating surgeon. It is very important to diagnose the damage early enough, preferably still during laparoscopy. Imaging investigations (ultrasound, ERCP, MRCP, cholangiography) may be helpful in establishing the diagnosis during the postoperative period.