Length of intraabdominal measurement of bowel (LIMB).

Background: Laparoscopic Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric surgeries. The steep associated learning curve is dependent on the training facility, laparoscopic experience, and overall procedural volume. William Beaumont Army Medical Center (WBAMC) has been accredited as a bariatric center of excellence and trains resident surgeons in the performance of RYGB. Objective: This study aimed to investigate the accuracy and precision of a bariatric center of excellence's training of surgical residents in terms of laparoscopic measurements of simulated small bowel. This will act as a surrogate for how well surgical residents learn to run the small bowel during bariatric procedures and how their accuracy and precision change over time in training. Setting: This study took place at William Beaumont Army Medical Center, a bariatric center of excellence and training institution. Methods: Participants included surgical residents from WBAMC. Participants used a laparoscopic trainer and two bowel graspers to measure both a collapsing garden hose (simulated bowel) and a nylon rope (control material) to 75 cm (cm) and 125 cm (cm), three times each, with recordings of time required to do so, actual distance measured, and technique used. Results: Fifteen residents participated in the study. Residents displayed accuracy of 21.6 %. 33%of residents were precise for the 75 cm measurement, and 53 % of residents were precise for the 125-cm measurement. PGY-4 residents were the most accurate while PGY-3 residents were the most precise. There were no statistical differences between junior (PGY 1-4) and senior residents (PGY 5-6) in accuracy or precision in the measurement of 75-cm or 125-cm. No statistical differences were found measuring the hose versus rope in accuracy nor precision. PGY-4 residents completed the task in the least amount of time while PGY-2 residents took the longest to complete each task. Conclusions: In general, residents are neither precise nor accurate in measurements of simulated bowel lengths, and experience does not contribute to either. Time in residency correlates with laparoscopic speed but not with accuracy nor precision. Extrapolating this data to attending surgeons suggests that estimated lengths of small bowel that are 'run' or measured during laparoscopic cases are neither accurate nor precise. More investigation must be performed in this area.

Recurrent pancreatitis due to intraductal papillary mucinous neoplasm in a young adult.

A young adult male presented with recurrent pancreatitis and a 2.2 cm mixed duct intraductal papillary mucinous neoplasm (IPMN) located in the pancreatic body. Our patient presented at age 21 with his second hospitalization for acute pancreatitis within a year. A mixed duct IPMN with main ductal dilation was identified, which prompted additional workup. Based upon the findings the patient was counseled regarding the risks and benefits of surveillance versus surgery. The patient elected to undergo a robotic-assisted laparoscopic distal pancreatectomy and splenectomy. Final pathology revealed an IPMN involving branch and main pancreatic ducts with low and focally high-grade dysplasia. IPMNs are increasingly being identified. Consensus guidelines generally propose surveillance, but management in young adults can be complex. Herein we present the second youngest reported case and highlight the continued need for consensus management guidelines.

Prospective randomized double-blind controlled trial of continuous local anesthetic infusion to reduce narcotic use in laparoscopic sleeve gastrectomy.

BACKGROUND: In an era of cost containment and outcome-based medicine, bariatric surgeons are attempting to decrease perioperative morbidity and streamline care. One way of accomplishing this is by decreasing opioid use and hospital stay. Several studies of nonbariatric open procedures have shown that continuous infusion catheters (CIC) are beneficial. Bariatric surgeons frequently utilize CIC, but the data is sparse for the clinical efficacy in laparoscopic procedures. OBJECTIVE: Evaluate the efficacy of CIC in laparoscopic sleeve gastrectomy. SETTING: military teaching hospital. METHODS: In this single institution prospective randomized double-blind controlled study, 82 patients undergoing laparoscopic sleeve gastrectomy (LSG) received either .2% ropivacaine or .9% normal saline (placebo) via CIC. After discharge, total narcotic usage, total antiemetic usage, pain scores, and hospital length of stay were evaluated. A one-way ANOVA was used to assess statistical significance. Power was 80% to detect 52 mg morphine equivalent difference. RESULTS: A total of 82 patients were enrolled, 39 received ropivacaine, and 43 received placebo. There was no statistically significant difference in narcotic usage between the ropivacaine group and placebo group, 51.9 mg versus 55.2 mg, respectively (P = .63). Ondansetron usage was 10.7 mg and 10.6 mg for ropivacaine and placebo groups. (P = .98). Average pain score was 3.0 for each group (P = .632). Total hospital length of stay was 37.5 hours for ropivacaine group and 38.1 hours for placebo group (P = .768). CONCLUSIONS: We found no difference in narcotic usage, antiemetic usage, pain scores, or hospital length of stay between ropivacaine and placebo groups. We conclude there is no utility of CIC in LSG.

Patient attitudes to surgeons' attire in an outpatient clinic setting: substance over style.

BACKGROUND: It is believed that patients prefer that surgeons convey a professional appearance with traditional business attire and white laboratory coat. We performed a prospective study to assess patient opinions regarding traditional attire versus the wearing surgical scrubs in the outpatient setting. METHODS: During a 5-month period, surgeons alternated wearing traditional clothing and surgical scrubs. Adult patients were given a questionnaire assessing their preferences regarding surgeons' clothing. RESULTS: Six hundred twelve patients returned the questionnaire. The majority felt that scrubs were appropriate attire for physicians. Half of the patients felt that wearing white laboratory coats is necessary. A minority felt that their surgeon's dress affects their opinion regarding the care they received. There was no difference between responses regardless of the attire actually worn. CONCLUSIONS: Surgeon's clothing choice does not significantly influence patient's opinion of the care they receive. Patients do not have strong preferences for white coats or more traditional surgical attire.

Relationship between varying Roux limb lengths and weight loss in gastric bypass.

BACKGROUND: The optimal Roux limb length for gastric bypass is unknown. Therefore, the effect of Roux limb length on weight loss and nutritional deficiency after a Roux-en-Y gastric bypass procedure was studied. METHODS: From September 2000 to February 2004, 165 Roux-en-Y gastric bypass surgeries were performed at William Beaumont Army Medical Center. One-year follow-ups were completed on 97 patients. Roux limbs varied from 100 cm to 150 cm, based on the patient's body mass index (BMI). Roux limb lengths were compared with 1-year changes in absolute weight, BMI, and nutritional levels. RESULTS: In the 97 patients, average age at the time of surgery was 44 years (range, 20-63). Average BMI was 46.7 +/- 6.6 kg/m(2) before surgery and 30.9 +/- 5.8 kg/m(2) at 1-year follow-up. Average absolute weight loss at 1 year was 43.7 +/- 12.8 kg. A statistically significant linear relationship existed between Roux limb length and reductions in BMI and absolute weight. No relationship existed between Roux limb length and changes in nutrient levels. CONCLUSION: A linear relationship exists between Roux limb length and 1-year weight loss.

Emergency nursing: historical, current, and future roles.

Building upon a historical context, the current and future roles of the clinical emergency nurse are reviewed. For several reasons, emergency nurse availability is expected to be insufficient to meet staffing demands in the near future. Emergency physicians can partner with emergency nurses and hospital administrators to pursue the following strategies for addressing the nursing shortage: (1) improve the workplace environment by improving nurse-to-patient ratios and avoiding the boarding of admitted patients in the emergency department (ED); (2) refocus the emergency nurse job description to patients and their families; (3) promote mutually supportive relationships and comradeship between emergency nurses and physicians; (4) create an environment that allows unique solutions to staff scheduling and accommodates shiftwork; (5) increase nursing wages, and recognize special contributions of emergency nurses with financial reward; (6) identify and promote the personnel of the hospital ED as members of an elite unit; (7) develop preceptorships and internships for nurses new to emergency nursing and invest in clinical specialists or nurse-mentors to assist in "on-the-job" instruction of nurses with previous experience; and (8) invest in nursing education. Taking these steps today will strengthen the ED health care safety net for decades to come.

Emergency nursing: historical, current, and future roles.

Building upon a historical context, the current and future roles of the clinical emergency nurse are reviewed. For several reasons, emergency nurse availability is expected to be insufficient to meet staffing demands in the near future. Emergency physicians can partner with emergency nurses and hospital administrators to pursue the following strategies for addressing the nursing shortage: 1) improve the workplace environment by improving nurse-to-patient ratios and avoiding the boarding of admitted patients in the emergency department (ED); 2) refocus the emergency nurse job description to patients and their families; 3) promote mutually supportive relationships and comradeship between emergency nurses and physicians; 4) create an environment that allows unique solutions to staff scheduling and accommodates shiftwork; 5) increase nursing wages, and recognize special contributions of emergency nurses with financial reward; 6) identify and promote the personnel of the hospital ED as members of an elite unit; 7) develop preceptorships and internships for nurses new to emergency nursing and invest in clinical specialists or nurse-mentors to assist in "on-the-job" instruction of nurses with previous experience; and 8) invest in nursing education. Taking these steps today will strengthen the ED health care safety net for decades to come.

The use of simvastatin for the prevention of gallstones in the lithogenic prairie dog model.

BACKGROUND: Surgery for morbid obesity is rapidly increasing. Patients undergoing bariatric surgery are prone to gallstone development during the rapid weight loss. These patients are often given medications such as ursodeoxycholic acid to prevent gallstone formation; however, these medications are often poorly tolerated by patients, who subsequently discontinue them. We performed a study in a lithogenic animal model to assess the effectiveness of a potential alternate medication for gallstone prevention. METHODS: 20 male prairie dogs were randomly separated into 2 groups and fed a lithogenic diet for 28 days. The study group animals were given 2.5 mg of the HMG-CoA reductase inhibitor simvastatin. Total cholesterol and triglycerides were measured and an open cholecystectomy was performed on each animal at the conclusion of the study period. The gallbladder was visually inspected for gallstones and microscopic biliary cholesterol crystal formation. RESULTS: There was a decrease of 36% in the total cholesterol of the study animals compared to controls. The animals treated with simvastatin showed gallstone formation in 5/10 (50%) of animals, compared with 6/10 (60%) of control animals. The study animals demonstrated microscopic cholesterol crystal formation in 80%, identical to the number found in the control animals. CONCLUSION: Despite a reduction in cholesterol, simvastatin prevented neither gallstone formation nor biliary cholesterol crystals in this animal model. Given the rapid increase in the number of bariatric surgical procedures coupled with the poor tolerance of ursodeoxycholic acid, viable alternatives should continue to be sought for these patients.

Implementation of sentinel lymph node biopsy for breast cancer by surgeons in the Department of Defense.

BACKGROUND: Sentinel lymph node biopsy (SLNB) for the evaluation of women with invasive breast cancer is rapidly gaining acceptance. The purpose of this study was to assess how surgeons in the Department of Defense (DOD) are incorporating SLNB into practice. METHODS: Surgeons at all DOD hospitals were telephonically surveyed regarding their current practices with SLNB. RESULTS: Of 66 DOD hospitals 23 (35%) are currently performing SLNB. Eleven hospitals (11 of 23, 48%) are academic centers, while 12 (12 of 23, 52%) are not teaching facilities. Seventeen (17 of 23, 77%) are in the learning phase of SLNB and follow SLNB with an axillary dissection. Eighteen (18 of 23, 78%) of facilities have surgeons who learned the procedure in residency/fellowship training. Sixteen (16 of 23, 70%) use a combination of isosulfan blue dye and sulfur colloid radioisotope. Surgeons performing SLNB are not aware of the method of examination of the sentinel node at their institution at 6 of 23 (26%) of hospitals. CONCLUSIONS: Increasing numbers of surgeons in the DOD Healthcare System are performing SLNB. The majority learned the procedure in residency or fellowship and are using a combination of blue dye and radioisotope for the performance of SLNB.

A new method of continuous venovenous rewarming.

PURPOSE: Hypothermia is a significant problem in medicine and is part of a deadly triad, including hypothermia, acidosis, and coagulopathy. Multiple methods of rewarming are used to treat moderate hypothermia. The purpose of this study was to compare the effectiveness of continuous venovenous rewarming (CVVR) using the FMS 2000 (Belmont Instrument Corp., Billerica, Massachusetts) in conjunction with external rewarming techniques versus external rewarming alone in the porcine model. METHODS: Ten subject animals, each weighing approximately 40 kg, were evenly divided and randomly assigned to either a control group using external rewarming techniques alone or the CVVR group utilizing the FMS 2000 in addition to the external rewarming techniques used in the control group. Hypothermia was induced in the swine model using cold water immersion to achieve a core temperature of 30 degrees C. Both esophageal and rectal temperature probes were used to monitor and record core body temperatures every 15 minutes during the experiment. Each study animal was then rewarmed until a core temperature of at least 37 degrees C was recorded in both the esophageal and rectal probes. The animals were observed clinically for 3 days after the study. RESULTS: The average time required to rewarm the control group was 253 minutes, compared with 113 minutes in the CVVR group. After 30 minutes of rewarming, the difference between the 2 groups with respect to core temperature was statistically significant (p = 0.002). A drop in core temperature after the initiation of rewarming, or after-drop, was noted in the control group animals, but not in the CVVR group. This difference was statistically significant after 15 minutes of rewarming (p = 0.015) CONCLUSIONS: Venovenous rewarming utilizing the FMS 2000 fluid management system is more effective than is standard therapy alone for rewarming in the moderately hypothermic porcine model. This finding may prove clinically useful in the treatment of patients suffering from moderate hypothermia.

Prevalence of teaching sentinel lymph node biopsy for breast cancer in general surgery residency programs.

PURPOSE: Sentinel lymphadenectomy (SLNB) for the evaluation of clinically negative lymph nodes in women with invasive breast cancer is rapidly gaining acceptance within the surgical community. The purpose of this study was to document the prevalence of teaching SLNB to residents in general surgery training programs in the United States. METHODS: The Fellowship and Residency Electronic Interactive Database (FREIDA) was searched for a listing of all general surgery residency programs. A short questionnaire was mailed to the program director of each residency program listed. The program directors were asked whether general surgery residents are taught the technique of performing SLNB for breast cancer, and how the procedure is performed at their institutions. RESULTS: Of the 255 surgical programs listed in FREIDA, 191 or 75% responded to the survey. Of responding programs, 92% are currently teaching surgical residents SLNB, whereas 4% plan on adding SLNB to the curriculum within the next academic year. A total of 74% of programs are performing SLNB as part of an organized hospital protocol, whereas 40% routinely follow SLNB with an axillary node dissection. A total of 89% of the programs use both sulfur colloid radioisotope and isosulfan blue dye, whereas 7% use dye alone, and 4% use only radioisotope. CONCLUSIONS: The practice of performing SLNB for the purpose of detecting occult nodal metastases in breast cancer is being taught at most surgery training programs in this country. In the less than 6 years since the modification of this technique for the treatment of breast disease, it has become the standard of care for treating women with invasive breast cancer with clinically negative axillary lymph nodes at training hospitals in the United States.