Bariatric surgery patient perceptions and willingness to consent to resident participation.

BACKGROUND: Many bariatric surgery programs are located at teaching hospitals, where they are integral to the training of surgical residents. OBJECTIVES: The purpose of this study was to examine preexisting bariatric patient perceptions and willingness to allow resident participation in their surgery. SETTING: Madigan Army Medical Center, Tacoma, Washington, USA. METHODS: Anonymous questionnaire was given to bariatric patients at their preoperative appointment at an academic teaching hospital. The survey captured demographic characteristics, overall opinions of teaching programs, and willingness to consent to various scenarios of trainee participation. Univariate and multivariate analyses were performed. RESULTS: One hundred eight patients (93% female) completed the questionnaire. Most patients (92.4%) expressed overall support for their procedure being performed at a teaching hospital. When presented with several realistic scenarios, most patients would consent to having a staff surgeon operate and residents/students observe (86%). However, only 56% of patients would consent to a resident assisting staff during a procedure and barely 14% of patients would consent to staff surgeon observing. An independent factor associated with increased willingness to consent to resident participation included patients whose first choice would be to undergo surgery at a teaching hospital (P< .05). CONCLUSION: Overall, patients expressed support for the teaching hospital model and resident education and participation. However, their willingness to consent to specific realistic scenarios involving various levels of resident participation in their surgery ranged widely. Although patients prefer detailed informed consent, it has the potential to negatively affect resident participation and training.

The weekend effect: does time of admission impact management and outcomes of small bowel obstruction?

AIMS: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. METHODS: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004-2011. RESULTS: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). CONCLUSIONS: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

The hidden war: humanitarian surgery in a combat zone.

BACKGROUND: Humanitarian surgical care (HSC) provided during wartime plays a substantial role in military operations, but has not been described or quantified beyond individual experiences. METHODS: Prospective survey was conducted of all military members deployed to Iraq or Afghanistan between 2002 and 2011. RESULTS: There were 266 responses. On average, surgeons had been in practice for 3 years at their 1st deployment and the majority were not fellowship trained. HSC was performed on all body systems and patient populations, including surgery for malignancy. Although 30% of responders performed surgeries they had never done before as a staff surgeon, 84% felt well prepared by their residency. The majority felt that performing HSC improved unit readiness (60%), benefited local population (64%), and contributed to counterinsurgency operations (54%). CONCLUSION: Over our 10-year period, hundreds of military surgeons performed countless HSC cases in Iraq and Afghanistan and the majority felt that HSC had numerous benefits.

Effects of histone deacetylase inhibition on 24-hour survival and end-organ injury in a porcine trauma model: a prospective, randomized trial.

BACKGROUND: Valproic acid (VPA) is a histone deacetylase inhibitor that has been shown to improve early resuscitation from hemorrhagic shock. We sought to examine whether there is a sustained benefit of VPA in a survival model of severe injury. METHODS: Yorkshire swine (n = 36) were randomized to three groups as follows: (a) control, (b) VPA (single dose), and (c) VPA (two doses at 12 hours apart). Animals underwent a 35% volume-controlled hemorrhage, followed by aortic cross-clamping for 50-minute duration, at which time VPA (400 mg/kg) was administered intravenously. Animals then underwent protocol guided resuscitation with crystalloid and vasopressor infusions for up to 24 hours. The primary end point was animal survival; secondary end points included hemodynamics, physiology, and histologic evidence of end-organ injury. RESULTS: Mean duration of survival was significantly longer in the control group (15.8 hours, n = 11) compared with single-dose VPA (12.6 hours, n = 9, p < 0.02). Redosing VPA at 12 hours provided no survival benefit. During cross-clamp, animals that received VPA required significantly less lidocaine compared with the control animals (32.8 mg vs. 159.4 mg, p = 0.03). Animals that received VPA also required significantly greater quantities of intravenous fluids per hour (p < 0.01) and higher epinephrine doses (p = 0.01). VPA administration was associated with earlier evidence of cardiac suppression (decreased cardiac output, increased pulmonary wedge pressures, and systemic vascular resistance; p < 0.05). VPA was associated with renal end-organ histologic protection and improved levels of blood urea nitrogen and creatinine at all time points (p < 0.05). CONCLUSION: Despite previous reports citing improved early outcomes with VPA administration, VPA did not improve resuscitation or mortality in a survival model with severe injury. VPA did show some evidence of prolonged renal protection. No benefit of redosing VPA was identified. VPA had a cardiac depressant effect that may be dose dependent and should be studied further.

Optimum cystic duct closure: a comparative study using metallic clips, ENSEAL, and ENDOLOOP in swine.

BACKGROUND: Metal clips are commonly used to secure the cystic duct during cholecystectomy, although use of an ENDOLOOP (Ethicon Endo-Surgery, Blue Ash, OH) is often touted as a more secure closure when postoperative endoscopic retrograde cholangiopancreatography (ERCP) is anticipated. The objective of this study was to test the strength of 3 different cystic duct closure methods in a model simulating postoperative biliary insufflation. METHODS: The extrahepatic biliary system, including common bile duct, gallbladder, and cystic duct, was harvested en bloc from 22 swine postmortem. A cholecystectomy was performed and the cystic duct was secured using 1 of 3 randomly assigned methods: metallic clips (Ethicon Endo-Surgery), an ENDOLOOP (Ethicon Endo-Surgery), or an ENSEAL tissue sealing device (Ethicon Endo-Surgery). The common bile duct was cannulated with a pressure-monitoring system and insufflated with air. The burst pressures, location of rupture, and size of the common bile duct and cystic duct were recorded and compared. RESULTS: There were 7 pigs each in the ENDOLOOP and ENSEAL groups and 8 in the metallic clip group, with no statistical significance between cystic and common bile duct size. Mean burst pressure was 432 mm Hg for metallic clips, 371 mm Hg for the ENDOLOOP, and 238 mm Hg for the ENSEAL device (P = .02). Post hoc analysis revealed clips to be statistically superior when compared with the ENSEAL (P= .01). There was no statistical difference between the ENDOLOOP and metal clips or between the ENDOLOOP and the ENSEAL. CONCLUSIONS: All 3 closure methods successfully secured the cystic duct, with mean burst pressures exceeding 195 mm Hg. Metallic clips demonstrated the highest burst pressures and no cystic duct stump leaks. This study challenges the traditional dogma of additionally securing the cystic duct with an ENDOLOOP when postoperative biliary instrumentation is expected and also suggests that an adequately secure closure may be obtained with thermal sealing devices.

Examining the relevance of the physician's clinical assessment and the reliance on computed tomography in diagnosing acute appendicitis.

BACKGROUND: The aim of this study was to examine the relevance of clinical assessment in diagnosing appendicitis in the current medical environment, in which routine use of computed tomography (CT) has become the norm. METHODS: A retrospective review was conducted, analyzing patient demographics, Alvarado clinical assessment scoring, and radiologic and pathologic results. RESULTS: A total of 664 patients were identified. Higher Alvarado scores were significantly associated with pathologically confirmed appendicitis (low, 87%; moderate, 92%; high, 96%; P = .05). As clinical assessment scores increased, use of CT decreased significantly (low, 97%; moderate, 85%; high, 79%; P = .01). The negative appendectomy rate for patients with clinical assessments consistent with appendicitis was 4%, compared with 3% associated with CT. Regardless of assessment scores, 82% of the cohort underwent CT. From a random sample of 100 charts, 87% of initial emergency department plans stratified disposition on the basis of the results of CT. CONCLUSIONS: Although physical examination remains crucial, CT has become the primary modality dictating care of patients with presumed appendicitis.

Operating room efficiency improvement after implementation of a postoperative team assessment.

INTRODUCTION: Operating room time is highly resource intensive, and delays can be a source of lost revenue and surgeon frustration. Methods to decrease these delays are important not only for patient care, but to maximize operating room resource utilization. The purpose of this study was to determine the root cause of operating room delays in a standardized manner to help improve overall operating room efficiency. METHODS: We performed a single-center prospective observational study analyzing operating room utilization and efficiency after implementing an executive-driven standardized postoperative team debriefing system from January 2010 to December 2010. RESULTS: A total of 11,342 procedures were performed over the 1-y study period (elective 86%, urgent 11%, and emergent 3%), with 1.3 million min of operating room time, 865,864 min of surgeon operative time (62.5%), and 162,958 min of anesthesia time (11.8%). Overall, the average operating room delay was 18 min and varied greatly based on the surgical specialty. The longest delays were due to need for radiology (40 min); other significant delays were due to supply issues (22.7 min), surgeon issues (18 min), nursing issues (14 min), and room turnover (14 min). Over the 1-y period, there was a decrease in mean delay duration, averaging a decrease in delay of 0.147 min/mo with an overall 9% decrease in the mean delay times. With regard to overall operating room utilization, there was a 39% decrease in overall un-utilized available OR time that was due to delays, improving efficiency by 2334 min (212 min/mo). During this study interval no sentinel events occurred in the operating room. CONCLUSIONS: A standardized postoperative debrief tracking system is highly beneficial in identifying and reducing overall operative delays and improving operating room utilization.

Training surgeons and the informed consent process: routine disclosure of trainee participation and its effect on patient willingness and consent rates.

OBJECTIVES: To examine patient perceptions and willingness to participate in resident education and to assess the effect on patient willingness and consent rates. DESIGN: Anonymous questionnaire designed to capture demographics, overall opinions of teaching programs, and willingness to consent to various scenarios of trainee participation. Descriptive and univariate analyses were performed. SETTING: Tertiary-level referral center. PATIENTS: Three hundred sixteen individuals scheduled for elective surgery. MAIN OUTCOME MEASURES: Consent rates for various scenarios. RESULTS: Of the 316 patients who completed the questionnaire, most expressed overall support of resident training: 91.2% opined that their care would be equivalent to or better than that of a private hospital, 68.3% believed they derived benefit from participation, and most consented to having an intern (85.0%) or a resident (94.0%) participate in their surgical procedure. However, when given specific, realistic scenarios involving trainee participation, major variations in the consent rate were observed. Affirmative consent rates decreased from 94.0% to 18.2% as the level of resident participation increased. Patients also were more willing to consent to the participation of a senior resident (83.1%) vs a junior resident (57.6%) or an intern (54.5%). Patients overwhelmingly opined that they should be informed of the level of resident participation and that this information could change their decision of whether to consent. CONCLUSIONS: Most patients expressed approval of teaching facilities and resident education. However, consent rates were significantly altered when more detailed information was provided and they declined with increasing levels of resident participation. Providing detailed informed consent is preferred by patients but it could adversely affect resident participation and training.