Surgical simulation: a current review.

BACKGROUND: Simulation tools offer the opportunity for the acquisition of surgical skill in the preclinical setting. Potential educational, safety, cost, and outcome benefits have brought increasing attention to this area in recent years. Utility in ongoing assessment and documentation of surgical skill, and in documenting proficiency and competency by standardized metrics, is another potential application of this technology. Significant work is yet to be done in validating simulation tools in the teaching of endoscopic, laparoscopic, and other surgical skills. Early data suggest face and construct validity, and the potential for clinical benefit, from simulation-based preclinical skills development. The purpose of this review is to highlight the status of simulation in surgical education, including available simulator options, and to briefly discuss the future impact of these modalities on surgical training.

Endoluminal and transluminal surgery: current status and future possibilities.

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include "incisionless," "endoluminal," "transluminal," and "natural orifice" transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.

Prophylactic total gastrectomy for familial gastric cancer.

BACKGROUND: An autosomal dominant syndrome of diffuse gastric cancer has been reported with germline mutations in the E-cadherin (CDH1) gene and has been identified in approximately 14 families and 50 individuals worldwide. Penetrance of the gene is 70% to 80%, and the average age of onset of gastric cancer is 37 years. These characteristics have led to the consideration of prophylactic total gastrectomy in family members with CDH1 mutations. METHODS: We report here the first use of prophylactic gastrectomy in 6 asymptomatic members of 2 families (2 males, 4 females; ages 22, 27, 28, 35, 39, and 40) based on family pedigree and genetic analysis. Total gastrectomy was performed via an upper midline incision, and reconstruction of the gastrointestinal tract was done via a Roux-en-Y esophagojejunostomy. Complete removal of all gastric mucosa was documented intraoperatively, and confirmation was made that only esophageal mucosa remained at the proximal specimen margin. RESULTS: The gastric specimens appeared normal, and the results of routine pathologic examination were negative for cancer. All specimens from patients who tested positive for E-cadherin mutations were subjected to a research protocol of microscopic sectioning in which 150 to 250 tissue blocks were examined. All of these patients had microscopic foci of cancer, often at multiple sites, with overlying normal gastric mucosa. CONCLUSIONS: E-cadherin gene mutations in association with familial gastric cancer is a new disease for which prophylactic surgery must be considered. The morbidity of this operation is much higher than that for other genetic diseases, but the alternative is a mortality risk of more than 80% at a young age.

Urachal-sigmoid fistula in an adult male.

Urachal cysts are unusual anomalies resulting from incomplete closure of the urachus. They comprise 38 per cent of urachal abnormalities. They present commonly in childhood, and there are only 20 reported cases of urachal cysts presenting in a person over the age of 40. Only one reported case appears of urachal-colonic fistula, and this was in the setting of colonic diverticulitis. This report presents the second reported case of urachal-colonic fistula and the first case of a fistula in a patient with a normal colon. The pathophysiology and management of urachal cyst are discussed.

Endoscopic retrograde cholangiopancreatography in a general surgery training program.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex procedures performed by endoscopists. ERCP has been performed primarily by gastroenterologists. There have been no reports in the literature regarding ERCP training within the framework of a general surgery residency program. The purpose of this study was to review ERCPs performed by surgical attendings and resident staff during a 6-year period and compare the success and complication rates with those found in published gastroenterological series. There were a total of 193 ERCPs performed on 171 patients for a success rate of 82.4 per cent and a complication rate of 6.7 per cent. A resident was the primary endoscopist in 51 procedures, with 42 (82.4%) successes and 2 complications (3.9%). There were no significant differences noted between our series and national complication rates, and between attending and resident procedures (P < 0.05, Chi-square analysis). This study has shown that surgical endoscopists can perform ERCP with success rates over 80 per cent, the currently regarded standard of expertise. The complication rates for these ERCPs were lower than accepted complication rates cited in current gastroenterological series. The results of this study support the hypothesis that ERCPs can be performed safely in a surgical residency.

Endoscopic evaluation of the postoperative stomach.

The endoscopic assessment of the postoperative stomach is one of the most challenging areas in endoscopy. This is a function of the plurality of disease entities and anatomic variations with which the endoscopist must be familiar in order to interpret the findings in this setting. At the same time, the diagnostic and therapeutic use of endoscopy in the postoperative environment is magnified because of the opportunity it provides to achieve information and relieve disability in situations of inherently significant morbidity. With the continuing maturation of endoscopic techniques, it is likely that the endoscopist of the future will have an increasingly significant role in the pre- and postoperative assessment and treatment of the patient with foregut pathology.

Delayed gallstone abscess following laparoscopic cholecystectomy.

Delayed infectious complications following elective laparoscopic cholecystectomy have not been well delineated in the medical literature. Irretrievable spillage of gallbladder contents at the time of laparoscopic cholecystectomy is not rare, and has generally been felt to be of little consequence, particularly in the nonacute setting. The case presented documents an instance of delayed gallstone abscess formation after elective laparoscopic cholecystectomy. While rare, such cases highlight the need for refined techniques to prevent gallbladder, perforation during this procedure and to allow laparoscopic recovery of small gallstones spilled at the time of cholecystectomy.

Surgical endoscopy fellowships. What difference do they make?

This study was conducted to evaluate the career impact of a formalized surgical endoscopy fellowship. Sixteen surgeons who have completed this training were surveyed via questionnaire. Twelve individuals were found to be in teaching settings, 10 had academic appointments, and 12 had published in the endoscopic and gastrointestinal literature. Gastrointestinal endoscopy constituted a mean of 28% of these surgeons' practices. Gastrointestinal surgery was the focus of a mean of 51% of their operative experience, and laparoscopic surgery constituted a mean of 40% of their surgical activity. Twelve of these individuals performed ERCP as part of their clinical practice, and 11 performed advanced laparoscopic surgical procedures. Relationships with nonsurgical endoscopic colleagues were considered positive for 5 surgeons, negative for 7, and neutral for 4. Professional relationships with nongastroenterologic physicians were uniformly positive or neutral. We conclude that formal surgical endoscopy fellowships facilitate subsequent academic and educational activity, foster surgical practices oriented toward gastrointestinal disease, and impact relationships with nonsurgical colleagues in a variable fashion.

Acute superior vena cava syndrome after central venous catheter placement.

Most cases of superior vena cava (SVC) syndrome are secondary to malignant disease and subacute in their presentation. Acute cases of SVC syndrome have been described, with the majority of these being precipitated by thrombosis after central venous catheterization. The authors report a case of acute SVC syndrome after central venous catheter placement, which was not due to thrombosis, but rather caused by a catheter occluding a previously subclinical stenosis of the SVC. Resolution of the clinical SVC syndrome occurred after catheter withdrawal.

Bleeding after endoscopic sphincterotomy as an underestimated entity.

Hemorrhage is the most frequent complication of endoscopic sphincterotomy, with a reported incidence of 2 to 9 per cent. Previous reports have generally defined this complication clinically, leaving the issue of occult bleeding after sphincterotomy essentially unaddressed. Seventy-five serial sphincterotomies were reviewed to further assess this complication. Nine patients had clinically evident hemorrhage and 27 patients had occult bleeding manifested only by a decrement in hematologic parameters, for a total postsphincterotomy bleeding rate of 48 per cent. No statistically significant risk factors for bleeding were delineated. Endoscopically recognized bleeding at the time of the sphincterotomy was 47 per cent sensitive and 85 per cent specific in predicting postprocedural bleeding. Significant delayed hemorrhage was manifest in three patients, one of whom had clinically occult bleeding. We conclude that bleeding complicates endoscopic sphincterotomy much more frequently than previously reported, although often in a clinically occult manner. Significant delayed bleeding can occur, and may not be clinically apparent. Bleeding recognized endoscopically at the time of sphincterotomy is an insensitive but relatively specific predictor of postprocedural bleeding. As use of endoscopic sphincterotomy increases, careful surveillance for hemorrhagic complications, as well as efforts to identify factors predisposing to the same, will be of increasing importance.

Endoscopic retrograde hemorrhoidal sclerotherapy using 23.4% saline: a preliminary report.

Historically, injection sclerotherapy has had a prominent role in the treatment of symptomatic hemorrhoids. Concern over sclerosant-related morbidity and dissatisfaction with anoscopic injection techniques has limited the application of this modality in the United States. This study reports an initial evaluation of 23.4% saline, used as a nonallergenic sclerosant, in the flexible endoscopic treatment of symptomatic internal hemorrhoids. Initial results in 19 patients with symptomatic grade I, II, or III hemorrhoids suggest that the technique is very effective in relieving bleeding, and frequently alleviates prolapse as well. The technique has proven to be well tolerated and associated with high patient satisfaction and low complication rates, with no serious complications noted. This modality is eminently suited for single session examination and therapy of the patient undergoing endoscopic evaluation for lower gastrointestinal bleeding whose findings are limited to hemorrhoidal disease.