Role of early thoracoscopy for management of penetrating wounds of the chest.

Most nonlife-threatening penetrating wounds of the chest (PWC) are treated with a chest tube alone. This may be inadequate because missed injuries, retained hemothorax, or foreign material may be difficult to address later. Early thoracoscopy should improve outcome. We conducted a retrospective review of 88 stable patients with PWC initially treated with a chest tube and had retained a hemothorax beyond 48 hours. Twenty-seven underwent an early video-assisted thoracoscopy (VATS). Fifty-five were observed, chest tubes were manipulated, or an additional one placed. The outcome was compared with the National Trauma Data Bank and controlled for Injury Severity Score. Early VATS reduced length of stay (4.3 vs 9.4 days), days in the intensive care unit (1.3 vs 3.2), and open thoracotomy (0 vs 7). A chest tube undertreats a nonlife-threatening PWC correctable by timely VATs.

The impact of minimally invasive surgery on residents' open operative experience: analysis of two decades of national data.

SUMMARY: Over the past 2 decades, the operative experience of surgical residents has undergone major changes due to advances in the science and technology of surgery, treatment modality, growth of subspecialties, work hour regulations, and an emphasis on shorter hospitalization. METHOD: We performed a comprehensive statistical analysis of national data from ACGME (1998-2008), with a focus on changes in the component operations. RESULTS: Since 1993, when minimally invasive surgery was first recorded in ACGME data base, the US residents' open operative experience began to register a continuing decline. Today, a quarter of the resident's operations are closed procedures. During the same period, trauma operative experience has decreased by 50%. If the decline in open operations continues at this rate, within 10 years it will drop to less than 60% of that in 1993. Gastrointestinal (especially biliary) operations are the most affected. Changes in ACGME data format of component operations made it difficult to determine the effect of work hour limit by looking at total operations alone. CONCLUSION: Training in open operative surgery, the foundation of the craft of surgery, is on the decline. Lack of operative trauma hurts intra-operative crisis management and decision making. These deficiencies deserve educational effort at a higher priority than accorded so far.

Simplified management of low-energy projectile extraperitoneal rectal injuries.

INTRODUCTION: Since minimally invasive approach for fecal diversion in low-velocity extraperitoneal rectal injuries (EPRI) has a lower morbidity than open, and since computed tomography (CT) scan is helpful in ruling out concomitant intraperitoneal injuries (IPI), we utilized both modalities to simplify management of such injuries. METHODS: Retrospective review of stable patients with EPRI, treated with laparoscopic assisted diversion, after a CT scan, compared with patients with similar injuries that had a negative laparotomy and a colostomy. RESULTS: The laparoscopy group had a shorter length of stay (3 +/- 2 days versus 7 +/- 2 days), earlier return of bowel function (3 +/- 2 days versus 5 +/- 2 days) and fewer infectious complications. If the CT scan was negative for IPI, none were found on open exploration or laparoscopy. CONCLUSION: If IPI are ruled out with a preoperative CT scan, laparoscopy-assisted colostomy is safe and less morbid.

Diagnosis of penetrating injuries of the pharynx and esophagus in the severely injured patient.

BACKGROUND: Diagnosis of penetrating pharyngeal and esophageal injuries are difficult when the patient has severe facial injuries, is obese or intubated, and hemodynamically unstable. Radiologic aids may be either unsuitable or unreliable. Videoendoscopy, preferably by the trauma surgeon, affords direct visualization at the bedside and is timely and expeditious. METHODS: Patients included in the study had penetrating injuries to the face/neck or torso. Evaluation began with careful assessment of the trajectory, followed by videoendoscopy and a contrast study. Data collected included the accuracy of diagnosis (compared with anatomic findings), time required to perform the studies, and complications resulting from both tests and repair. RESULTS: Thirty-three patients were included in the study. Contrast study detected all esophageal injuries, but failed to detect any hypopharyngeal injuries particularly in the intubated patients. Videoendoscopy detected all injuries, hypopharyngeal and esophageal in intubated and nonintubated patients. CONCLUSIONS: Radiologic studies should not be used for pharyngeal injuries. Although radiologic studies accurately diagnosed penetrating injuries of the esophagus, it is not as expeditious as videoendoscopy performed by the trauma surgeon. Videoendoscopy should be part of the trauma surgeons' armamentarium.

Multiple organ procurement: a tool for teaching operative technique of major vascular control.

BACKGROUND: With the reduction in residents work hours and time for operative training, particularly for major vascular exposure and control, supplemental education experience is needed. Participation in multiple organ procurement (MOP) may correct this deficiency. METHODS: Senior residents were given written quiz before and after transplantation rotation and participation in MOP, for knowledge in operative exposure of great vessels of the abdomen and chest. RESULTS: Twenty residents, with an average of six organ retrievals per resident, showed significant improvement in surgical knowledge of vascular exposure and control after transplantation rotation. CONCLUSION: Participation in MOP increases resident's familiarity with anatomy and operative technique for expeditious exposure of the major vessels.

Screening laboratory and radiology panels for trauma patients have low utility and are not cost effective.

BACKGROUND: Routine laboratory and radiology panels as part of the initial evaluation of the trauma patient are prevalent practices. This is a study of utility and cost effectiveness of this practice. METHODS: During a 3-month period, trauma panels were analyzed for cost and impact on patient care in our institution. RESULTS: Four hundred ten consecutive patients had 3,982 studies (cost $417,839) performed of which 1,292 (cost $114,753) were abnormal and only 253 (cost $36,703) were clinically contributory. CONCLUSIONS: Routine panels are not useful or cost effective. Negative results contribute little to management. Selective and targeted studies should be indicated by the secondary survey, and may result in substantial cost savings ($1,500,000 per year at our institution).

How surgical residents spend their training time: the effect of a goal-oriented work style on efficiency and work satisfaction.

HYPOTHESIS: When work hours are limited, improving residents' work efficiency allows more time for key training activities, reduces frustration, and improves work satisfaction. DESIGN: Prospective control study. SETTING: General surgical service with a trauma program. PARTICIPANTS: Five full-time attending physicians, a resident team of 9 members, and 3 surgical assistants. INTERVENTION: Reorganization of work habits based on a goal-oriented work style. MAIN OUTCOME MEASURES: Changes of time spent in key activities; punctuality for operations, clinics, and conferences; residents' work satisfaction, physical fatigue, and mental stress; and attending physician and patient evaluations of residents. RESULTS: A goal-oriented work style reduced round time and nonpurposeful time and improved punctuality for key education activities. More operative time could be accommodated within the work-hours limits. Residents' work satisfaction improved while mental stress was reduced. Patient satisfaction scores also increased. CONCLUSIONS: Residents' work is generally inefficient. Reduced work hours should be accompanied by work-habit reform to make the best use of residents' training time.

Residents managed trauma adequately using their own radiological interpretation as compared with "nighthawk" radiologists.

OBJECTIVE: To determine whether senior surgical residents can independently interpret radiologic studies for the trauma patients under their care. METHOD: Five senior surgical residents (PGY-4 and -5) participated in this prospective study. The residents independently read trauma films as part of the emergency assessment, documenting their interpretations to be compared with the reports by nighthawk radiologists. RESULTS: During a period of 4 months, 426 films of 124 trauma patients admitted to a Level II trauma center were read by one of the five senior surgical residents, and by nighthawk radiologists. Approximately 22% of these were penetrating injuries and the remainder blunt trauma. Residents identified 127 injuries versus 128 injuries identified by the radiologists, with 99.2% agreement. The residents missed two injuries, while the radiologists missed one. CONCLUSIONS: Senior surgical residents can independently and accurately interpret the trauma radiology studies, a skill essential for time-critical decision making.

Pancreas-sparing duodenectomy is effective management for familial adenomatous polyposis.

Duodenal adenocarcinoma remains the leading cause of cancer death in familial adenomatous polyposis patients following colectomy. Stratification based on Spigelman's criteria provides a means for determining therapy. Spigelman stage IV patients have been selected for pancreas-sparing duodenectomy. Twenty-one patients underwent resection between 1992 and 2004, with a mean age of 58 +/- 11 years. The mean time from colectomy to duodenectomy was 27 +/- 13 years. Invasive cancer was found in the distal duodenum in one patient. Operative time averaged 327 +/- 61 minutes with a mean blood loss of 503 +/- 266 ml. There was no mortality, and eight patients (38%) had 14 complications: six (29%) with delayed gastric emptying, four (19%) with biliary/pancreatic anastomotic leak, one with pancreatitis, and one with wound infection. There were two reoperations: one for delayed gastric emptying and one for an early biliary leak. Mean length of stay was 15 +/- 10 days. Two late complications occurred: a stomal ulcer and an intestinal obstruction at 48 and 24 months, respectively. Mean follow-up was 79 months (range, 3-152 months). Two patients developed polyps in the advanced jejunal limb and were endoscopically treated. Pancreas-sparing duodenectomy represents a definitive treatment for advanced duodenal polyposis and can obviate the need for pancreaticoduodenectomy.

How much time do surgical residents need to learn operative surgery?

BACKGROUND: We calculated the time a resident spent to acquire the average operative experience before mandated duty hours, to generate a standard for curriculum redesign. METHODS: By using data from 2002 to 2003 furnished by the Residency Review Committee for Surgery, and the operation times of attending surgeons in a hospital consortium, the time devoted to operative surgery over 5 years of training were calculated. RESULTS: An average of 2753 hours or 14.3% of 19,200 hours (5 years of 80-hour work weeks) were spent as a chief surgeon, 272 hours as an assistant, and another 938 hours for immediate preoperative and postoperative attendance. The average total time for operative training was 3963 hours or 20.6% of 5 years of 80-hour weeks (16.5 h/wk). CONCLUSIONS: The database is useful for redesigning the surgical curriculum for the mandated duty hours. It also may be used to determine rapidly if a program currently is providing sufficient time for operative surgery.

The contribution of laparoscopy in evaluation of penetrating abdominal wounds.

BACKGROUND: Penetrating abdominal wounds are traditionally explored by laparotomy. We investigated prospectively the role of laparoscopy within a defined protocol for management of penetrating abdominal wounds to determine its safety and advantages over traditional operative management. STUDY DESIGN: The study inclusion criteria were: stab and gun shot abdominal wounds, including junction zone injuries; stable vital signs; and absence of contraindications for laparoscopy. Diagnostic end points included detection of peritoneum or diaphragm violation, visceral injuries, and other indications for laparotomy. Systematic examination was undertaken using a multiport technique whenever the peritoneum or diaphragm had been violated. All repairs were done by open operation. RESULTS: A total of 40.6% of patients with penetrating trauma fulfilled study criteria (52 patients). Of these, 33% had no peritoneal penetration; 29% had no visceral injuries despite violation of peritoneum or diaphragm; 38% had visceral injuries, of which 40% (mainly liver and omentum) required no intervention. Twelve patients (23% of total) had open repairs. No missed injuries or death occurred in the study. Overall, 77% of penetrating injuries with stable vital signs avoided exploratory laparotomy. Compared with National Trauma Data Bank information for patients with the same Injury Severity Scores, hospitalization was reduced by more than 55% for the entire series. CONCLUSIONS: Laparoscopy for penetrating abdominal injuries in a defined set of conditions was safe and accurate, effectively eliminating nontherapeutic laparotomy and shortening hospitalization.

Meeting the 80-hour work week requirement: what did we cut?

OBJECTIVE: To meet the new accreditation requirement, small programs with limited manpower must make hard decisions to safeguard quality. We devised a system to meet the requirement in our own environment, making the obligatory cuts in educational components as prioritized by the trainees. This study examined what aspect of training is impacted and the residents' perception of the resulting change. METHOD: In a fully accredited program where the baseline work hours/week exceeded the new requirement by over 20% even with full deployment of physician's assistants, the strategies used included reducing external rotations, transitioning PGY-3 into senior responsibility, and integrating senior rotations to 2 hospitals into 1 (2 weeks/month), so that time in a lower volume hospital helped to bring the monthly average to target. Residents were surveyed at 6-month intervals for their perception of the change. RESULTS: Compared with baseline, the new system averaged 77 +/- 5 hours/week, significantly reduced from before (98 +/- 12, p < 0.01), but with greatly reduced continuity of care (28 +/- 10% vs. 88 +/- 8%, p < 0.001), reduced consultations seen (19 +/- 4 vs. 36 +/- 7 per week, p < 0.001), reduced conference attendance (5.7 vs. 3.5 per week, p < 0.001), and reduced operations (55 +/- 7 vs. 68 +/- 9 per week for the program). External rotations have been reduced by 3 months, and outpatient clinics merged from 5 to 2. Surveys showed improvement in fatigue-related issues for junior residents. Senior residents were dissatisfied with the reduced educational components. CONCLUSION: Reducing work hours cannot be accomplished without reducing educational components. Unlike junior residents, senior residents felt less fulfilled with the new system and do not benefit in physical fatigue.

Malaria resistance in Guyana, South America

Two imported cases of Chloroquine-, Fansidar-, and quinine-resistant Plasmodium falciparum malaria were diagnosed and treated in Trinidad, West Indies. The infections were cured by the administration of a multiple drug treatment regime of 45 mg Primaquine phosphate, 1.8 g sulphadoxine, 75 mg Pyrimethamine (Fansidar), and 650 mg quinine sulphate. Recrudescence has not occurred over the past 30 months. (AU)