Update regarding the society of American Gastrointestinal and Endoscopic Surgeons (SAGES) grant distribution and impact on recipient's academic career.

BACKGROUND: Small seed grants strongly impact academic careers, result in future funding, and lead to increased involvement in surgical societies. We hypothesize that, in accordance with the SAGES Research and Career Development committee mission, there has been a shift in grant support from senior faculty to residents and junior faculty. We hypothesize that these junior physician-researchers are subsequently remaining involved with SAGES and advancing within their academic institutions. METHODS: All current and previous SAGES grant recipients were surveyed through Survey Monkey™. Questions included current academic status and status at time of grant, ensuing funding, publication and presentation of grant, and impact on career. Results were verified through a Medline query. SAGES database was examined for involvement within the society. Respondent data were compared to 2009 data. RESULTS: One hundred and ninety four grants were awarded to 167 recipients. Of those, 75 investigators responded for a response rate 44.9%. 32% were trainees, 43% assistant professors, 16% associate professors, 3% full professors, 3% professors with tenure, and 3% in private practice. This is a shift from 2009 data with a considerable increase in funding of trainees by 19% and assistant professors by 10% and a decrease in funding of associate professors by 5% and professors by 10%. 41% of responders who were awarded the grant as assistant or associate professors had advanced to full professor and 99% were currently in academic medicine. Eighty-two percent indicated that they had completed their project and 93% believed that the award helped their career. All responders remained active in SAGES. CONCLUSION: SAGES has chosen to reallocate an increased percentage of grant money to more junior faculty members and residents. It appears that these grants may play a role in keeping recipients interested in the academic surgical realm and involved in the society while simultaneously helping them advance in faculty rank.

Consumer-based technology for distribution of surgical videos for objective evaluation.

BACKGROUND: The Global Operative Assessment of Laparoscopic Skill (GOALS) is one validated metric utilized to grade laparoscopic skills and has been utilized to score recorded operative videos. To facilitate easier viewing of these recorded videos, we are developing novel techniques to enable surgeons to view these videos. The objective of this study is to determine the feasibility of utilizing widespread current consumer-based technology to assist in distributing appropriate videos for objective evaluation. METHODS: Videos from residents were recorded via a direct connection from the camera processor via an S-video output via a cable into a hub to connect to a standard laptop computer via a universal serial bus (USB) port. A standard consumer-based video editing program was utilized to capture the video and record in appropriate format. We utilized mp4 format, and depending on the size of the file, the videos were scaled down (compressed), their format changed (using a standard video editing program), or sliced into multiple videos. Standard available consumer-based programs were utilized to convert the video into a more appropriate format for handheld personal digital assistants. In addition, the videos were uploaded to a social networking website and video sharing websites. RESULTS: Recorded cases of laparoscopic cholecystectomy in a porcine model were utilized. Compression was required for all formats. All formats were accessed from home computers, work computers, and iPhones without difficulty. Qualitative analyses by four surgeons demonstrated appropriate quality to grade for these formats. CONCLUSIONS: Our preliminary results show promise that, utilizing consumer-based technology, videos can be easily distributed to surgeons to grade via GOALS via various methods. Easy accessibility may help make evaluation of resident videos less complicated and cumbersome.

Unsupervised procedures by surgical trainees: a windfall for private insurance at the expense of graduate medical education.

BACKGROUND: Surgical faculty cannot always be present while trainees perform minor procedures. Fees are not obtained for these unsupervised services because Medicare rules do not allow residents and fellows to bill. Medicare already supplements hospitals via medical education funds and thus reimbursement for trainee services would constitute double billing. Private insurance companies, however, do not supplement trainees' salaries and thus benefit when they are not charged for these procedures. The objective is to determine whether significant revenue is lost to private insurers for unsupervised procedures performed by surgical trainees. METHODS: We retrospectively evaluated a prospective database of procedures performed by residents and fellows from March 1998 through 2007. All procedures were entered by the trainees into a computerized electronic note system. Unsupervised procedures were not billed to insurance carriers. RESULTS: During the study period, 14,497 minor procedures were performed without attending supervision, of which 13,343 had valid current procedural terminology codes. Total charges for these procedures would have been $10,096,931. For patients with private insurance companies (PICs), $6,876,000 could have been billed. Using our historic collection ratios, $2,269,083 in revenue was lost, or $232,726 annually. CONCLUSIONS: Trainees perform a significant number of unsupervised procedures on patients with private insurance without charge. This pro bono service represents a significant amount of lost income for teaching institutions. Private insurance companies benefit financially from Medicare billing regulations without contributing to education. Billing for these services might help offset the costs of graduate medical education.

Decrease in sweet taste in rats after gastric bypass surgery.

BACKGROUND: The literature contains evidence that Roux-en-Y gastric bypass (RYGB) surgery has an effect in humans on taste and preference for carbohydrate-rich foods. This study tested the hypothesis that RYGB affects sweet taste behavior using a rat model. METHODS: Male Sprague-Dawley rats underwent either RYGB or sham surgery. Then 4 weeks after surgery, the rats were given taste-salient, brief-access lick tests with a series of sucrose concentrations. RESULTS: The RYGB rats, but not the sham rats, lost weight over the 5-week postoperative period. The RYGB rats showed a significant decrease in mean licks for the highest concentration of sucrose (0.25-1.0 mol/l) but not for the low concentrations of sucrose or water. CONCLUSIONS: The findings showed that RYGB surgery affected sweet taste behavior in rats, with postsurgical rats having lower sensitivity or avidity for sucrose than sham-treated control rats. This finding is similar to human reports that sweet taste and preferences for high-caloric foods are altered after bypass surgery.

Endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

INTRODUCTION: Roux-en-Y gastric bypass is an excellent option for weight loss in the morbidly obese. Unfortunately, some patients do have weight regain or insufficient weight loss. Revisional bariatric surgery is not without risk. Less invasive techniques may provide alternative treatments for patients that regain weight or have insufficient weight loss. This video demonstrates a technique of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass. METHODS: The technique is applied to patients who have had weight regain or insufficient weight loss following gastric bypass. Patients who have lost the feeling of satiety, undergone reeducation and recounseling of dietary changes, and have documented dilated gastrojejunostomy on upper endoscopy and/or a barium study are offered this technique. If the gastojejunostomy is larger than 12 mm, sodium morrhuate is injected with an endoscopic needle circumferentially. RESULTS: The gastrojejunostomy is injected with 6-30 cc of sodium morrhuate. By visual inspection, the anastomosis usually appears smaller after the procedure. Most patients report a subjective feeling of satiety after the endoscopic sclerotherapy. Reinjection after 3 months has been performed in some patients. Except mild nausea, the patients have experienced no morbidity or mortality from the procedure. CONCLUSIONS: Endoscopic sclerotherapy may offer an alternative treatment for dilated gastrojejunostomy after gastric bypass. The technique described in the video is a relatively easy, safe method that may become the first line of therapy in patients who have a dilated gastrojejunostomy and have lost the feeling of satiety after gastric bypass with an associated weight gain.

Technical skills rotation for general surgery residents.

BACKGROUND: Technical skills are an important part of any general surgery residency curriculum. With the demands of limited work weeks, it is imperative that educators create novel methods of teaching technical skills to their residents. Our program utilizes a dedicated month to help accomplish this. This study hypothesized that general surgery residents would report a positive effect of a dedicated technical skills rotation. METHODS: Residents who had undergone a 1 mo rotation in technical skills during their first year were asked to fill out a survey concerning their experience. During the 1-mo rotation, the residents had almost no clinical responsibilities. Teaching of technical skills was performed with various activities, including video content (VC), virtual reality simulators (VR), open foam procedures (OF), laparoscopic box trainers (BT), surgical equipment in-service (SE), and animate sessions (AS). Responses were given on a Likert scale (1-10) with higher numbers being more positive responses. RESULTS: There were seven residents in this study. The residents gave a very positive response to the overall rotation (9.4) and exposure to laparoscopic procedures (9.6). The other responses were enthusiastic as well: exposure to open procedures (8.9) and preparation for operative room (9.4). After their rotation, the residents were comfortable performing a laparoscopic cholecystectomy (9.2), a hand-sewn anastomosis (8.7), and a stapled anastomosis (9.4). The residents found theses activities helpful in increasing order: VC (7.8), VR (8.0), BT (9.0), ES (9.7), OF (9.8), and AS (9.8). CONCLUSIONS: A 1-mo dedicated technical skills rotations was perceived to be extremely positive by the residents. The residents felt very comfortable performing a laparoscopic cholecystectomy, a hand-sewn anastomosis, and a stapled anastomosis. With the 80-h work week, alternatives to learning technical skills in the operating room are essential. Further studies need to be performed to determine if this rotation aids in accomplishing this goal.

Human epicardial adipokine messenger RNAs: comparisons of their expression in substernal, subcutaneous, and omental fat.

We compared the gene expression of inflammatory and other proteins by real-time quantitative polymerase chain reaction in epicardial, substernal (mediastinal) and subcutaneous sternal, upper abdominal, and leg fat from coronary bypass patients and omental (visceral) fat from extremely obese women undergoing bariatric surgery. We hypothesized that (1) epicardial fat would exhibit higher expression of inflammatory messenger RNAs (mRNAs) than substernal and subcutaneous fat and (2) epicardial mRNAs would be similar to those in omental fat. Epicardial fat was clearly different from substernal fat because there was a far higher expression of haptoglobin, prostaglandin D(2) synthase, nerve growth factor beta, the soluble vascular endothelial growth factor receptor (FLT1), and alpha1 glycoprotein but not of inflammatory adipokines such as monocyte chemoattractant protein-1, interleukin (IL)-8, IL-1beta, tumor necrosis factor alpha, serum amyloid A, plasminogen activator inhibitor-1, or adiponectin despite underlying coronary atherosclerosis. However, the latter inflammatory adipokines as well as most other mRNAs were overexpressed in epicardial fat as compared with the subcutaneous depots except for IL-8, fatty acid binding protein 4, the angiotensin II receptor 1, IL-6, and superoxide dismutase-2. Relative to omental fat, about one third of the genes were expressed at the same levels, whereas monocyte chemoattractant protein-1, cyclooxygenase-2, plasminogen activator inhibitor-1, IL-1beta, and IL-6 were expressed at far lower levels in epicardial fat. In conclusion, epicardial fat does not appear to be a potentially more important source of inflammatory adipokines than substernal mediastinal fat. Furthermore, the expression of inflammatory cytokines such as IL-6 and IL-1beta is actually higher in omental fat from obese women without coronary atherosclerosis. The data do not support the hypothesis that most of the inflammatory adipokines are expressed at high levels in epicardial fat of humans.

The inflammatory response seen when human omental adipose tissue explants are incubated in primary culture is not dependent upon albumin and is primarily in the nonfat cells.

BACKGROUND: The present studies were designed to investigate the changes in gene expression during in vitro incubation of human visceral omental adipose tissue explants as well as fat cells and nonfat cells derived from omental fat. METHODS: Adipose tissue was obtained from extremely obese women undergoing bariatric surgery. Explants of the tissue as well as fat cells and the nonfat cells derived by digestion with collagenase were incubated for 20 minutes to 48 h. The expression of interleukin 1beta [IL-1beta], tumor necrosis factor alpha [TNFalpha], interleukin 8 [IL-8], NFkappaB(1)p50 subunit, hypoxia-inducible factor 1alpha [HIF1alpha], omentin/intelectin, and 11beta-hydroxysteroid dehydrogenase 1 [11beta-HSD1] mRNA were measured by qPCR as well as the release of IL-8 and TNFalpha. RESULTS: There was an inflammatory response at 2 h in explants of omental adipose tissue that was reduced but not abolished in the absence of albumin from the incubation buffer for IL-8, IL-1beta and TNFalpha. There was also an inflammatory response with regard to upregulation of HIF1alpha and NFkappaB1 gene expression that was unaffected whether albumin was present or absent from the medium. In the nonfat cells derived by a 2 h collagenase digestion of omental fat there was an inflammatory response comparable but not greater than that seen in tissue. The exception was HIF1alpha where the marked increase in gene expression was primarily seen in intact tissue. The inflammatory response was not seen with respect to omentin/intelectin. Over a subsequent 48 h incubation there was a marked increase in IL-8 mRNA expression and IL-8 release in adipose tissue explants that was also seen to the same extent in the nonfat cells incubated in the absence of fat cells. CONCLUSION: The marked inflammatory response seen when human omental adipose tissue is incubated in vitro is reduced but not abolished in the presence of albumin with respect to IL-1beta, TNFalpha, IL-8, and is primarily in the nonfat cells of adipose tissue.

Release of 12 adipokines by adipose tissue, nonfat cells, and fat cells from obese women.

The relative release in vitro of endothelin-1, zinc-alpha2-glycoprotein (ZAG), lipocalin-2, CD14, RANTES (regulated on activation, normal T cell expressed and secreted protein), lipoprotein lipase (LPL), osteoprotegerin (OPG), fatty acid-binding protein 4 (FABP-4), visfatin/PBEF/Nampt, glutathione peroxidase-3 (GPX-3), intracellular cell adhesion molecule 1 (ICAM-1), and amyloid A was examined using explants of human adipose tissue as well as the nonfat cell fractions and adipocytes from obese women. Over a 48-h incubation the majority of the release of LPL was by fat cells whereas that of lipocalin-2, RANTES, and ICAM-1 was by the nonfat cells present in human adipose tissue. In contrast appreciable amounts of OPG, amyloid A, ZAG, FABP-4, GPX-3, CD14, and visfatin/PBEF/Nampt were released by both fat cells and nonfat cells. There was an excellent correlation (r = 0.75) between the ratios of adipokine release by fat cells to nonfat cells over 48 h and the ratio of their mRNAs in fat cells to nonfat cells at the start of the incubation. The total release of ZAG, OPG, RANTES, and amyloid A by incubated adipose tissue explants from women with a fat mass of 65 kg was not different from that by women with a fat mass of 29 kg. In contrast that of ICAM-1, FABP-4, GPX-3, visfatin/PBEF/Nampt, CD14, lipocalin-2, LP, and endothelin-1 was significantly greater in tissue from women with a total fat mass of 65 kg.

Dexamethasone and the inflammatory response in explants of human omental adipose tissue.

Dexamethasone is a synthetic glucocorticoid that is a potent anti-inflammatory agent. The present studies examined the changes in gene expression of 64 proteins in human omental adipose tissue explants incubated for 48h both in the absence and presence of dexamethasone as well as the release of 8 of these proteins that are putative adipokines. The proteins were chosen because they are inflammatory response proteins in other cells, are key regulatory proteins or are proteins with known functions. About 50% were significantly up-regulated while about 10% were unchanged and the remaining 40% were down-regulated. Dexamethasone significantly up-regulated the expression of about 33% of the proteins but down-regulated the expression of about 12% of the proteins. We conclude that dexamethasone is a selective anti-inflammatory agent since it inhibits only about one-fourth of the proteins up-regulated during in vitro incubation of human omental adipose tissue.

Omental reinforcement for intraoperative leak repairs during laparoscopic Roux-en-Y gastric bypass.

Leaks from the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) have the potential for significant morbidity and mortality. When intraoperative leaks are discovered, we choose to perform omental reinforcement around the gastrojejunostomy and pouch after suture repair of the leaks. This study examined the hypothesis that omental reinforcement would be useful after intraoperative leaks during LRYGB. Omental reinforcement was performed on gastrojejunostomies, in which leaks were seen, created using a circular stapler during LRYGB. Data were reviewed retrospectively on these patients. There were a total of 387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively. Leaks/dehiscences were repaired with sutures and then reinforced with omentum. None of these patient developed anastomotic leak postoperatively. Of the other 365 patients, there were four (1.1%) leaks from the gastrojejunostomy and/or gastric pouch. Omental reinforcement may be useful in decreasing the incidence of postoperative leaks when an intraoperative leak is encountered during LRYGB. However, omental reinforcement does not completely prevent a postoperative leak. Consideration of reinforcement with omentum may be given for patients in whom an intraoperative leak is noted.

Management of recurrent inguinal hernias after total extraperitoneal (TEP) herniorrhaphies.

INTRODUCTION: The laparoscopic repair offers clear advantages in recurrent inguinal hernias after open herniorrhaphy. Less clear is the role of laparoscopy for recurrences after previous laparoscopic inguinal herniorrhaphies. In this paper, we present our experience with both laparoscopic and open inguinal hernia repair of laparoscopic recurrences. METHODS: All patients who had undergone repair of recurrences after previous laparoscopic hernia repair from July 2004 to July 2007 were included in this study. Charts were reviewed for all these patients. RESULTS: Six patients were diagnosed with 7 recurrent inguinal hernias after laparoscopic repairs. All the initial laparoscopic repairs, except for one, were total preperitoneal (TEP) with the placement of lightweight polypropylene mesh. The average time from the initial repair to the diagnosis of recurrence was 20 months (range 3-84). Four of the 7 recurrences were treated with a laparoscopic approach. The other three recurrences were repaired in an open fashion as per the preoperative plan. In 2 of the laparoscopic cases, the peritoneal flap was not able to cover the mesh, so a tissue-separating mesh with fibrin sealant was utilized to cover the myopectineal orifice. No intra- or postoperative complications were recorded. There were no recurrences at an average follow-up of 14 months (range, 11-17). CONCLUSIONS: Laparoscopic repair can be offered to those patients with a recurrence after a previous laparoscopic repair. Further studies comparing laparoscopic repair versus open repair of recurrences after laparoscopic inguinal hernia repair will be helpful in defining the best approach when encountering these recurrences.

Intraoperative endoscopy and leaks after laparoscopic Roux-en-Y gastric bypass.

Postoperative leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) are a source of morbidity and mortality. Any intervention that would decrease leak rates after LRYGB would be useful. This investigation tested the hypothesis that postoperative leak rates are lower after LRYGB with the routine use of intraoperative endoscopy (EN). Consecutive patients who underwent LRYGB were included. Intraoperative leak testing with air and methylene blue through an orogastric tube (OG) was used in the first 200 patients. Intraoperative endoscopy was used after the first 200 patients. There were 400 patients in this study. Preoperative demographics did not differ between groups. The intraoperative leak rate of the EN group was double the OG group (8 vs 4%; P = not significant), although the difference was not statistically significant. The OG group had a postoperative leak rate of 4 per cent with a mortality rate of 1 per cent. The EN group had a postoperative leak rate of 0.5 per cent with a mortality rate of 0 per cent. The difference in leak rates was statistically significant (P < 0.04). Despite the issues of learning curve, EN demonstrates more intraoperative leaks than OG, indicating EN may be a more sensitive test than OG. Routine use of EN is associated with less postoperative leaks after LRYGB.

Laparoscopic revision of failed fundoplication and hiatal herniorraphy.

OBJECTIVE: The aim of this study was to evaluate the mechanisms of failure after laparoscopic fundoplication and the results of revision laparoscopic fundoplication. BACKGROUND: Laparoscopic Nissen fundoplication has become the most commonly performed antireflux procedure for the treatment of gastroesophageal reflux disease, with success rates from 90 to 95%. Persistent or new symptoms often warrant endoscopic and radiographic studies to find the cause of surgical failure. In experienced hands, reoperative antireflux surgery can be done laparoscopically. We performed a retrospective analysis of all laparoscopic revision of failed fundoplications done by the principle author and the respective fellow within the laparoscopic fellowship from 1992 to 2006. METHODS: A review was performed on patients who underwent laparoscopic revision of a failed primary laparoscopic fundoplication. RESULTS: Laparoscopic revision of failed fundoplication was performed on 68 patients between 1992 and 2006. The success rate of the laparoscopic redo Nissen fundoplication was 86%. Symptoms prior to the revision procedure included heartburn (69%), dysphagia (8.8%), or both (11.7%). Preoperative evaluation revealed esophagitis in 41%, hiatal hernia with esophagitis in 36%, hiatal hernia without esophagitis in 7.3%, stenosis in 11.74%, and dysmotility in 2.4%. The main laparoscopic revisions included fundoplication alone (41%) or fundoplication with hiatal hernia repair (50%). Four gastric perforations occurred; these were repaired primarily without further incident. An open conversion was performed in 1 patient. Length of stay was 2.5 +/- 1.0 days. Mean follow-up was 22 months (range, 6-42), during which failure of the redo procedure was noted in 9 patients (13.23%). CONCLUSION: Laparoscopic redo antireflux surgery, performed in a laparoscopic fellowship program, produces excellent results that approach the success rates of primary operations.

Internal Hernias and Nonclosure of Mesenteric Defects During Laparoscopic Roux-en-Y Gastric Bypass.

BACKGROUND: Internal hernias have been described after laparoscopic Roux-en-Y gastric bypass (LRYGB) as a major problem. Thus, many routinely close defects during LRYGB. In our technique, we do not close any defects. We hypothesize that not closing the defects would not cause a significant internal hernia rate diagnosed during reoperations. METHODS: Patients who were reoperated after LRYGB were included in this study. Only patients who had a laparoscopic or open exploration focused on inspecting for internal hernias are reported here. The LRYGB technique that was utilized included an antecolic, antegastric gastrojejunostomy, minimal division of the small bowel mesentery, a long jejunojejunostomy performed with three staple lines, adequate division of the omentum, and placement of the jejunojejunostomy above the colon in the left upper quadrant. RESULTS: There were a total of 387 patients who had LRYGB from 2002 to 2007 utilizing this particular technique. Fifty-four patients had a reoperation at an average of 24 (Range: 1-60) months postoperatively. The procedures were abdominoplasty, cholecystectomy, diagnostic laparoscopy, and lysis of adhesions. While two patients had a defect present, no patient had an internal hernia despite aggressive attempts to diagnose one. CONCLUSIONS: Internals hernias are not common after our particular method of LRYGB. Before adopting and advocating routine closure, surgeons should consider the surgical technique and the true associated incidence of internal hernias. We do not recommend routine closure of these defects with our technique.

Patient perception of medicare fee schedule of laparoscopic procedures.

INTRODUCTION: It seems that public perception is that physicians receive substantial payments for procedures. This investigation explores patient perception and opinion of Medicare reimbursements to surgeons related to laparoscopic surgery. Our hypothesis was that patients think the surgeon Medicare fee schedule is higher than actuality. METHODS: Patients filled out an IRB exempted survey. The survey included a written description of laparoscopic gastric bypass, laparoscopic adjustable gastric band placement, laparoscopic cholecystectomy and an initial patient visit for 30 minutes. All participants were asked to give their thoughts of what Medicare currently reimburses for these procedures as well as what the payment should be. The survey also asked other questions about reimbursement related to Medicare. RESULTS: There were 96 participants in the investigation with 43% of patients not filling in reimbursements for at least one procedure. Most patients (88%) looked at their bills from physicians and insurance companies carefully. For each procedure, the mean reimbursements were approximately 10 times higher than the patient perception of both the amount Medicare currently pays and the amount Medicare should pay compared to the actual fee. For the initial patient visit, the patients overestimated the payment by 158% and thought the Medicare should pay 199% of the actual fee. Most of the patients (98%) thought Medicare should pay more for more difficult cases and 85% thought Medicare should pay more if the patient visits the surgeon more times during the global period. While 32% of the patients feel Medicare pay physicians well, 91% thought that Medicare should increase fees. CONCLUSION: Most of our patients overestimated what Medicare currently pays for some laparoscopic procedures. Surgeons need to do a better job in educating patients and the general public about the Medicare fee schedule.

Comparison of two low-molecular-weight heparin dosing regimens for patients undergoing laparoscopic bariatric surgery.

BACKGROUND: Venous thromboembolic events (VTE) are a morbidity and mortality concern for patients undergoing laparoscopic bariatric surgery. Although VTE prophylaxis is recommended in bariatric surgery, data with regard to monitoring and appropriate dosing of low-molecular-weight heparin are limited. Enoxaparin prophylactic doses ranging from 30 to 60 mg every 12 h have been used for this population. The authors hypothesized that higher prophylactic enoxaparin doses (60 mg) would yield more appropriate heparin antifactor Xa (anti-Xa) concentrations than the 40-mg dosage for bariatric surgery patients. METHODS: Patients undergoing laparoscopic bariatric surgery by two surgeons during a 5-month period at one institution received enoxaprin 40 or 60 mg every 12 h. Anti-Xa levels were obtained 4 h after the first and third doses. Therapeutic levels were defined as 0.18 to 0.44 U/ml. Paired and unpaired t-tests and chi-square tests were used for statistical analysis as appropriate. RESULTS: The first-dose mean anti-Xa concentration was 0.173 U/ml in the 40-mg group and 0.261 U/ml in the 60-mg group (p < 0.005), compared with the third-dose mean anti-Xa levels of 0.21 and 0.43 U/ml, respectively (p < 0.001). After the third dose of enoxaparin, the percentage of patients with anti-Xa concentrations who remained subtherapeutic showed a statistically significant difference: 44% in the 40-mg group versus 0% in the 60-mg group (p = 0.02). However, no supratherapeutic anti-Xa concentrations were observed in the 40-mg group, whereas 57% of the third-dose levels in the 60-mg group were supratheraputic. The highest anti-Xa level was 0.54 U/ml, but none of the patients with this level experienced bleeding events. CONCLUSIONS: Enoxaparin 60-mg every 12 h was superior to a dosage of 40 mg every 12 h in achieving therapeutic anti-Xa concentrations and avoiding subtherapeutic anti-Xa levels. However, the 60-mg group had a number of supratherapeutic levels. Future studies evaluating the relationship of anti-Xa concentrations and outcomes with larger numbers of morbidly obese patients are needed.

Goal-directed laparoscopic training leads to better laparoscopic skill acquisition.

INTRODUCTION: Laparoscopic skills training outside the operating room is becoming the standard for educating surgical residents. Because of the restrictions on the work week, it is imperative for this training to be efficient. We hypothesized that goal-directed laparoscopic training (GDLT) would result in better skill acquisition than laparoscopic training without goals (LT). METHODS: Second-year general surgery residents participated in this study. Metrics were scores that incorporated time and errors. One group of residents (LT) went through a 10- week laparoscopic training course without goals; one group of residents (GDLT) was given goals to achieve during their course. Each group practiced for the same amount of time. The tasks were peg exercise, run the rope, pattern cutting, clip/cut vessel, extracorporeal knot tying, intracorporeal knot tying, and suturing device. Statistical analysis was performed via 2-tailed Mann-Whitney tests. RESULTS: There were 8 residents in the LT group and 7 residents in the GDLT. The GDLT group had statistically significant higher scores on 7 of the 8 tasks compared the LT group (P < .02 to P < .0001). The GDLT group performed better in the final task, suturing device, than the LT group, but this did not reach statistical significance (451 vs 414; P = .14). CONCLUSIONS: GDLT should be used by surgeons instead of LT. Future studies need to examine whether GDLT translates into a better operative technique and outcomes.