Training residents in laparoscopic colorectal surgery: is supervised surgery safe?

BACKGROUND: Colorectal resections are increasingly performed laparoscopically, and training in laparoscopic resections in the Netherlands has shifted from a post-residency fellowship to training in residency. The question remains if this supervised surgery affects short-term patient outcome. METHODS: Between January 2010 and July 2014, 523 consecutive patients, who underwent laparoscopic colorectal resection, were selected from a prospective single-center database. All data were obtained from the maintained database and retrospectively analyzed. We compared the short-term outcome of patients who underwent laparoscopic colorectal surgery by a supervised fifth- or sixth-year resident compared to patients who underwent laparoscopic colorectal surgery performed by a dedicated colorectal surgeon. Statistical analysis was performed using the Chi-square test for categorical variables and the t test for continuous variables. RESULTS: Almost 40 % of operations were performed by a resident with an even distribution in type of resection, except for the abdominal-perineal resection (residents vs. surgeon 3.57 vs. 8.26 %, p = 0.04) and the total number of patients who underwent preoperative chemoradiation (resident vs. surgeon 6.66 vs. 20.65 %, p = 0.04). No difference was found in operative time or per-operative blood loss. A higher conversion rate was found when surgery was performed by a supervised resident (residents vs. surgeon 17.34 vs. 9.17 %, p = 0.01), which could be attributed to case selection and one single year. No differences in major complications, oncological outcome and construction of a stoma were found. In the case of minor complications, a significantly increased percentage of bladder retention was found in the surgeon group (residents vs. surgeon 1 vs. 4.6 %, p = 0.03). CONCLUSIONS: In this study, we found that patient safety and short-term outcome are not adversely affected when laparoscopic colorectal surgery is performed by a supervised fifth- or sixth-year resident.

Selection of monitoring locations for storm water quality assessment.

Storm water runoff is a major contributor to the pollution of receiving waters. Storm water characteristics may vary significantly between locations and events. Hence, for each given location, this necessitates a well-designed monitoring campaign prior to selection of an appropriate storm water management strategy. The challenge for the design of a monitoring campaign with a given budget is to balance detailed monitoring at a limited number of locations versus less detailed monitoring at a large number of locations. This paper proposes a methodology for the selection of monitoring locations for storm water quality monitoring, based on (pre-)screening, a quick scan monitoring campaign, and final selection of locations and design of the monitoring setup. The main advantage of the method is the ability to prevent the selection of monitoring locations that turn out to be inappropriate. In addition, in this study, the quick scan resulted in a first useful dataset on storm water quality and a strong indication of illicit connections at one of the monitoring locations.

[Basal cell naevus syndrome as the cause of a chronic foot ulcer]. / Basaalcelnaevussyndroom als oorzaak van een chronisch voetulcus.

A 46-year-old man presented to the surgery outpatient clinic with an ulcer on top of his left foot. He had previously been diagnosed with basal cell naevus syndrome but had withdrawn from follow-up. His foot showed a deep ulcerating defect accompanied by profound necrosis extending to the metatarsophalangeal joints. There was a nodular skin defect over the first metatarsophalangeal joint, which was shown by histopathology to be a basal cell carcinoma, and the ulcer was bordered by a raised wall. Further physical examination revealed more than 200 dermal lesions which were identified by the dermatologist who was called in for consultation as basal cell carcinomas; multiple depressions due to abnormal local keratinisation were also seen on the palms of the hands and the soles of the feet. These findings led to a diagnosis of 'basal cell naevus syndrome'. The patient was treated by amputation of the lower leg followed by excision and curettage of the remaining basal cell carcinomas. At the time of the last follow-up, the patient was being checked periodically in the dermatology outpatient clinic. Basal cell naevus syndrome is a rare autosomal dominant hereditary disease. The prevalence is estimated to be between 1 in 57,000 and 1 in 164,000. Basal cell naevus syndrome is generally caused by a mutation in the 'patched homolog' (PTCH)-I gene, located on chromosome 9q22.3. Although the syndrome affects multiple organ systems, the most characteristic of this disorder is the appearance of multiple basal cell carcinomas.

Necrotizing soft tissue infection of the thigh: consider an abdominal cause.

BACKGROUND: Necrotizing soft tissue infection (NSTI) is a disastrous infection of the subcutaneous tissue and underlying fascial layers. Even if urgent treatment is started, mortality rates are high. Due to the paucity of specific cutaneous signs, early recognition is extremely difficult. This in turn causes a delay in diagnosis and worsens prognosis. Although NSTI can develop after a wide variety of causes, specific clues such as initial gram staining and a high index of suspicion should alert the clinician to an abdominal causative agent, which alters surgical treatment strategy. If detected early, prognosis for the patient is improved. METHODS: Four patients with NSTI of the thigh due to an abdominal origin are detailed regarding their clinical presentation, gram stain or culture, abdominal focus, and treatment. Based on our clinical experience and a review of the relevant literature, we address clinical challenges and controversies of importance. RESULTS: Current literature on NSTI recommends prompt surgical debridement and broad-spectrum antibiotic therapy. Our cases revealed that an abdominal focus is not uncommon; however, it can be easily missed, which delays treatment. All cases demonstrated polymicrobial gram stains and cultures, which can raise suspicion of and lead to determination of an abdominal focus. CONCLUSIONS: High clinical suspicion or a polymicrobial gram stain or culture should quickly lead to determination of an abdominal source. Early surgical exploration and focus treatment, together with prompt surgical debridement and broad-spectrum antibiotic therapy, could reduce mortality significantly.

Perforation of the esophagus caused by the insertion of an intragastric balloon for the treatment of obesity.

Obesity is an enduring chronic disease, with multifactorial etiology. Many procedures and solutions have been proposed in the last 25 years. If patients do not meet the criteria for bariatric surgery, intragastric balloons may be used to achieve weight reduction. Contraindications to balloon therapy are a large hiatal hernia, severe esophagitis, peptic ulceration and previous gastric surgery. Although intragastric balloons are advocated as safe devices, major complications such as intestinal obstruction, gastric perforation and gastric ulceration have been described. We report a case of esophageal rupture due to insertion of an intragastric balloon for the treatment of morbid obesity, for which no contraindication existed. When abnormal pain or discomfort arises, or esophageal damage is noted after insertion of an intragastric balloon, patients must be closely monitored to diagnose a possible esophageal rupture early and thereby prevent severe complications.

[Colostomy as a cause of deviation colitis in a blind-ended bowel segment]. / Colostoma als aanleiding voor deviatiecolitis in het blind eindigende darmsegment.

Two women aged 63 and 53 who had undergone colostomy for faecal incontinence, presented a few months later complaining of anal blood and mucous loss. On sigmoidoscopy, a previously healthy section of colorectum seemed to be inflamed. Local treatment with hydrocortisone and mesalazine and oral prednisolone did not relieve the symptoms. Subsequently the affected part of the colon was resected upon which the anal blood and mucous loss stopped. After a deviating stoma procedure, the colonic segment diverted from the faecal stream can develop signs of non-specific inflammation. The risk of colitis following the creation of a stoma is 0-50%. On systematic endoscopy 3-36 months following deviation, the risk of findings corresponding to deviation colitis is 50-100%. Symptoms are usually mild but can be so devastating that continuity of the faecal stream has to be restored or further resection is warranted.

Transcatheter arterial embolization in a hemodynamically unstable patient with grade IV blunt liver injury: is nonsurgical management an option?

The prevalence of liver injury in patients who have sustained blunt multiple trauma was reported to range from 1 to 8%. Because previous mortality rates were as high as 50-80% for severe hepatic injury, the choice of treatment was under intensive investigation. Whereas nonsurgical management was the standard treatment for the hemodynamically stable patient, there is no consensus on how to treat hemodynamically unstable patients. This report details the case of a patient who sustained blunt multiple trauma, resulting in a grade IV liver injury, graded according to the American Association for the Surgery of Trauma (AAST) Liver Injury Scale. With massive fluid and blood resuscitation, the patient was stable enough to be managed nonsurgically. With transcatheter arterial embolization (TAE), the left and right hepatic arteries were embolized with coils, which allowed for a good recovery. We hypothesize that TAE can be used in the hemodynamically unstable patient who responds to rapid fluid resuscitation and blood transfusion. We caution that there is insufficient evidence until now and would therefore not make any recommendations; however, we would question the need for surgery in unstable patients with this kind of injury in the future.