Gastric sleeve as an extra-anatomical roux for biliary reconstruction in a pediatric third liver transplant.

BACKGROUND: Sir Roy Calne in 1976 described "Biliary reconstruction is the Achilles heel of liver transplantation," and it remains true. In some patients, such as those with short-gut syndrome and concomitant biliary atresia, neither duct to duct nor Roux biliary reconstruction is feasible. METHODS: We present a case of child's third liver transplant (LT), where an innovative extra-anatomical biliary bypass was created using a sleeve from greater curvature of the stomach. RESULTS: The patient is well nearly 10 years following the LT. CONCLUSIONS: This technique could prove to be an important addition to the armamentarium of a surgeon in difficult retransplants and in patients with short-gut syndrome as it provides a viable option with good long-term outcome.

Redefining major hepatic resection for colorectal liver metastases: Analysis of 1111 liver resections.

INTRODUCTION: A major hepatic resection is currently defined as resection of 3 or more segments. The aim of this study was to analyse the post-operative morbidity and mortality of hepatic resections in relation to the number of segments excised. PATIENTS AND METHODS: From January 2000 to December 2010, 1111 liver resections were performed for colorectal liver metastases (CRLM). Data were collected from a prospectively maintained database and analysed according to the extent of resection performed. RESULTS: 457 patients had 1-2, 362 had 3-4 and 292 had 5-6 segments resected respectively. In comparing 1-4 vs. 5-6 segments, overall morbidity (16.7% vs 40.7%; p < 0.001), hepatic failure (0.6% vs 10.6%; p < 0.001); mean hospital stay (8 vs 13.5 days; p = 0.000), mean ICU stay (4.4 vs 6.5 days; p = 0.01), 60-day mortality (0.7% vs 3.4%; p = 0.002), and 90-day mortality (0.7% vs 3.4%; p = 0.002) were significantly different. When analysing the 3-4 vs 5-6 segment resections, morbidity (21.8% vs 40.7%; p < 0.001), hepatic failure (1.4% vs 10.6%; p = 0.000), 60-day mortality (0.7% vs 3.4%; p = 0.002), and 90-days mortality (0.8% vs 3.4%; p = 0.023) remained statistically significant. CONCLUSIONS: Differences in outcome would suggest a revision of the current classification. Only when 5 or more segments are excised for CRLM should a liver resection be considered "major".

How can we enhance undergraduate medical training in the operating room? A survey of student attitudes and opinions.

BACKGROUND AND PURPOSE: Teaching in the operating room (OR) may add substantial value to undergraduate medical education but at present, the value of this as a core-learning environment is unclear. We assessed student attitudes to see how the experience may be improved. METHODS: All medical students from University of Leeds, UK were invited to complete an online-based questionnaire. The questionnaire gathered quantitative and qualitative responses relating to previous experiences, acquired benefits, and desired improvements. Students rated their overall satisfaction on a 10-point scale. RESULTS: A total of 292 students (20.8%) responded to the survey, out of whom 91.4% had previous OR experience. The median overall satisfaction was 7/10; 43.1% described bad or unfavorable experiences. Common themes included feeling intimidated, unwelcome, or ignored by staff, unrealistic expectations of knowledge, and poor or inadequate learning experiences. Benefits of attending the OR were improvements in scrub technique (82.3%), knowledge of anatomy (72.3%), anesthetics (67.5%), and surgical procedures (86.1%). Desired improvements included more opportunity to participate in the procedure (74.4%), encouragement from supervisors (73.6%), improved teaching (71.4%), and better induction to the OR environment (56%). DISCUSSION AND CONCLUSIONS: Overall satisfaction of OR teaching is reasonable and many benefits are derived from attending the OR. However, bad experiences are common and this is detrimental to the student learning experience. The experience may be of increased value to undergraduate medical education within a dedicated and structured surgical teaching program.