New Trends at 25 Years: An American Board of Surgery Academic Certifying Examination Review Course.

BACKGROUND: In the 1980s, a small research group began identifying variables affecting applicant success on the American Board of Surgery (ABS) Certifying Examination (CE). We now report success and trends as we complete 25 years. We had multiple challenges as identified through faculty focus groups and participant feedback that needed to be addressed: increase the national optics of the program, integrate new innovative experiences, maintain the integrity of the collected data on excel files, incorporate national trends in surgery, attract experienced clinical volunteer faculty and staff, security of capital, and schedule management. METHOD: The primary purpose of the program is to define the root cause interfering with success on the ABS CE. All of the listed changes in course design (2012-2016) were entered into excel files along with participants demographics, including results of the pretesting modules, the communication inventory, all self-reported stressors, and interview results to track the effect of faculty interventions, trends and ABS outcomes. RESULTS: The profiles of the participants have changed over time, including: marital status, presence of DSM-5 stressors, gender, fellowship training, study habits, financial burdens, and international graduate status. International graduates demonstrated communication issues that were present, though rarely addressed, during residency training. The gradual absorption of junior faculty allowed a seamless transition over time as part of the succession plan. Although the national success rates on the CE were 72% to 80%, this program's success rate still remained in the 90 percentile (94%-97%) for those who followed their education improvement plan. Deidentified excel files will be converted to REDCap for preservation and analysis. DISCUSSION: The small course design has continued to be effective at identifying variables that interfere with success on the CE examination. The inclusion of additional PhD education scientists facilitated focused individual interventions. A pilot program for international graduate status residents is in development.

Emotional considerations and attending involvement ameliorates organ donation in brain dead pediatric trauma victims.

PURPOSE: The purpose of this study was to ascertain a strategy for maximizing parental consent for organ donation in traumatically injured children suffering from brain death. Our hypothesis was that appropriate attending surgeon involvement and delay in evaluating children for brain death leads to an increased percentage of organ donors. METHODS: From January 1993 to August 1999, the records of all children who died in a Level I trauma center were evaluated. Those children suffering brain death that were suitable for organ donation were entered into the study. Cases were reviewed for patient demographics, time to entry into brain death protocol (measured from time of admission), time to parent notification about brain death (measured from time of admission), specific attending involved in the case (with level of involvement), and success of organ donation request. In all, 43 charts were reviewed. RESULTS: Of 43 deaths, 33 were deemed suitable for donation. Age of suitable donors ranged from 1 month to 18 years. In all, 11 attending physicians were involved in the care of these children. Overall, 20 of 33 were organ donors (60%). When the attending surgeon was involved, donation success for organ retrieval was 86%, whereas if the attending was not involved personally, the success rate dropped to 23% (p < 0.04). One senior pediatric surgeon obtained a success rate of 12 of 12 children. It was this surgeon's policy to not initiate brain death protocols in children immediately on entry into the emergency room, but rather to delay initiation until family could be gathered and spend time with the affected child in order that the family could recover from the initial shock of trauma (always at least overnight). When time to initiation of brain death protocol was examined, success was obtained when a delay of 15.5 hours was respected, versus 7.0 hours when donation was requested but denied (p < 0.03). CONCLUSION: These data indicate that attending involvement is important when parents of brain dead children are asked about organ retrieval (p < 0.04). Delay in initiating brain death protocols in order for family members to deal with the shock of the initial trauma appears to increase willingness to participate in organ donation.

A population-based study of geriatric trauma in a rural state.

BACKGROUND: Urban geriatric trauma patients are known to die more often than their younger counterparts. Little is known of the fate of geriatric trauma patients in a rural environment where delays to definitive treatment are frequent. We hypothesized that rural trauma patients would do worse than their urban counterparts because of prolonged delays to definitive care. METHODS: Five-year retrospective analysis of all trauma deaths occurring within a rural state and retrospective outcome analysis of trauma patients admitted to a tertiary care facility who were less than 55 years old (defined as young) and 55 or more years old (defined as old). Outcome analysis was performed comparing old and young rural hospitalized patients to the Major Trauma Outcome Study data set collected in major urban trauma centers. RESULTS: Of the total trauma deaths in the state, 32.5% were old. Old patients were less likely to die at the scene of the injury than were their younger counterparts (R2 = 0.84, p < 0.001). Hospitalized old patients had a significantly higher mean Revised Trauma Score and a significantly lower Injury Severity Score, a higher complication rate, and a higher mortality rate than did hospitalized young patients. The young group had a significantly better survival (W = 0.59, Z = -3.49, p = 0.0001) than the MTOS data set, but the old group had a significantly worse survival (W = -1.8, Z = -3.49, p = 0.001). CONCLUSION: In a rural environment, old trauma patients die more commonly in the hospital than their younger counterparts, who die more commonly at the scene. Old trauma patients who die in the hospital were less severely injured than their younger counterparts who died in the hospital. Old patients admitted to this rural trauma center have a significantly worse survival than their urban counterparts despite the fact that young rural trauma patients do significantly better than their urban counterparts. Understanding the demographics of rural geriatric trauma may be useful in allocating resources in rural trauma system design. It must be understood that despite relatively low injury severity and physiologic stability, there is a significant potential for rural geriatric trauma patients to do poorly.

Nonoperative management of hepatic, splenic, and renal injuries in adults with multiple injuries.

BACKGROUND: Nonoperative management (NOM) of abdominal solid organ (ASO; liver, spleen, kidney) injuries from blunt trauma in adults has gained acceptance, but multisystem trauma remains a relative contraindication to NOM. METHODS: We reviewed the charts of 126 adult patients who underwent NOM of an ASO injury for success of NOM, transfusions, and complications. Patients were divided into two groups: group I had isolated ASO injuries (n = 48); group II had an ASO injury and at least one additional injury with an Abbreviated Injury Score > or = 2 (n = 78). RESULTS: NOM was successful 89.6% of group I and 93.6% of group II patients (p = 0.55). Group II had higher Injury Severity Scores (20.7 +/- 9.8 vs. 8.3 +/- 4.9 p < 0.05) and transfusion requirements (30.8% vs. 14.6%,p < 0.05) than group I. Complication rates were not different (group I, 20.8% vs. 26.9% group II, p = 0.58). CONCLUSION: NOM of ASO injuries may attempted in adult patients with multiple injuries without increased morbidity.

Perforation of the intrathoracic esophagus from blunt trauma in a child: case report and review of the literature.

Rupture of the intrathoracic esophagus from blunt trauma is an exceedingly rare injury in children and often presents on a delayed basis. The authors encountered a case of this unusual injury and review six additional cases found in the literature.

Financial aspects of providing trauma care at the extremes of life.

BACKGROUND: Children and the elderly are more likely to be underinsured compared with the general population of trauma patients. We performed financial analysis on all trauma patients admitted during an 18-month period to a Level I adult and pediatric trauma center to evaluate the financial impact of providing trauma care for children and the elderly. METHODS: Patients were categorized by age: PEDI<17 years, GERI>64 years and MID = 17 to 64 years. Reimbursement ratio (RR = reimbursement/cost; RR>1 = profit, RR<1 = loss), length of stay (LOS), and Injury Severity Score (ISS) were calculated for each age group. RESULTS: RR for GERI (RR = 0.99) was significantly lower than for PEDI (RR = 1.15) and MID (RR = 1.16). There was no difference in ISS, but the LOS of GERI was greater than that of PEDI and MID (p<0.05). Cost per patient and LOS were less in PEDI versus MID and GERI (p<0.05). CONCLUSION: Trauma care reimbursement for the elderly is inadequate, whereas pediatric trauma care costs less to deliver and is profitable to the trauma center.

Allogeneic fetal intestinal transplantation with FK506 immunosuppression.

PURPOSE: Small intestinal transplantation remains a significant clinical problem. Allogeneic fetal intestinal (AFI) transplantation shows promise, particularly regarding procurement; however, no studiesto date have evaluated the potential success of true allogeneic loci implantation. The authors hypothesized that isolated segments of AFI could be heterotopically transplanted but would require immunosuppression to survive. METHODS: Donor tissue was obtained from late-gestation Brown Norway rat fetuses with a histo-locus RTN and Fischer fetuses with a histo-locus RT1L. The recipients were adolescent male Fischer rats with a histo-locus RT1L. A 1.2-cm segment of fetal small bowel was implanted in the omentum of the recipient rat and allowed to mature for 5 weeks. Animals were then separated into five groups. Group A served as controls with syngeneic fetal intestinal (SFI) transplant. Group B received AFI with no immunosuppression; group C, AFI transplant with five days of FK506; group D, AFI with 10 days of FK506; and Group E, AFI with daily FK506 for the entire 5-week maturation period. Animals were killed on day 35. RESULTS: All animals gained weight over the maturation period. Groups B, C, and D had no viable transplant segments at day 35. Groups A and E both had well-developed viable segments confirmed by gross and histological evaluation. CONCLUSIONS: FK506 allows for normal intestinal development for use in allogeneic fetal bowel transplantation. With this observation, the use of fetal intestine transplanted into the portal circulation emerges as a potentially viable alternative to present intestinal transplant models.

Port-site recurrence after thoracoscopic resection of pulmonary metastasis owing to osteogenic sarcoma.

Video-assisted thoracic surgery (VATS) is being used increasingly to evaluate and treat intrathoracic pathology. Port-site seeding is a rare but feared complication when minimally invasive surgical techniques are used in the evaluation and treatment of malignancies. The authors report a case of port-site seeding after thoracoscopic resection of pulmonary metastasis from an osteogenic sarcoma.

Associated head injury should not prevent nonoperative management of spleen or liver injury in children.

The appropriate management of children with liver or spleen injuries and associated head injury after blunt trauma remains controversial. To evaluate the success rates for nonoperative management and the impact this approach has on both abdominal and head injury outcome, children recorded in the National Pediatric Trauma Registry were reviewed. From January 1, 1994 to April 1, 1995, 107 children (aged < 19) were identified with liver, spleen, and associated head injury from blunt trauma. Forty-five (42%) children had combined head and spleen injury, 51 (48%) had head and liver injury, and 11 (10%) had head, liver, and spleen injury. Only 18 (17%) required laparotomy (head and spleen injury, 9 (8%); head and liver injury, 5 (5%); and head, liver, and spleen injury, 4 (4%)). Overall, there were no differences in Glasgow Coma Scale scores for children requiring laparotomy compared with those managed conservatively (13 vs. 14, p > 0.05). For all groups, the mean Injury Severity Score was significantly higher for children requiring laparotomy (19 vs. 31, p < 0.05). However, when comparison of the groups was stratified for type of injury and severity, the transfusion requirements, mortality, and abdominal and neurologic morbidity were all improved in children managed nonoperatively. Contrary to previous guidelines in the literature for selection of patients for nonoperative management of blunt solid organ abdominal injury, the association of altered mental status from head injury with liver and spleen injuries should not impact the decision for observational management.

Management of esophageal varices in children by endoscopic variceal ligation.

Endoscopic variceal sclerotherapy (EVS) has been considered the mainstay of therapy for bleeding esophageal varices in adults. However, recent data have shown that endoscopic variceal ligation (EVL) is just as efficacious and has fewer complications than EVS. Although there are many reports concerning EVL in adults, only a few studies have been done in children. This report describes experience with EVL in 22 children with esophageal variceal hemorrhage. Eighty-seven EVL procedures were performed during a 9-year period in 22 children. The causes of portal hypertension were biliary atresia (10), portal vein thrombosis (8), chronic active hepatitis (1), cirrhosis secondary to cystic fibrosis (2), and primary sclerosing cholangitis (1). The age range at the onset of variceal bleeding was 8 months to 19 years. Twelve patients had EVS before EVL treatment was begun. Distal esophageal varices (one to four per session) were mechanically ligated using an elastic band ligature device attached to a flexible endoscope. The aim of therapy was obliteration of distal esophageal varices by EVL, every 2 to 4 weeks, until eradication. Subsequent EVL was dictated by the status of the varices. Outcome was assessed with respect to survival, rebleeding, status of varices, and complications. The patients underwent a mean of four sessions of EVL (range, one to eight). Four patients subsequently underwent liver transplantation. Of the 18 patients remaining (average follow-up period, 5.3 years), 12 had their varices eradicated (average of four EVL sessions), four are still in treatment, one has not been evaluated in the past 4 years, and one died of liver failure. Complications included bleeding between sessions (6 patients), cervical esophageal perforation (1 patient), and transient fever (2 patients). No child has experienced symptoms of esophageal stenosis or gastroesophageal reflux. Two patients died of liver disease, unrelated to bleeding from portal hypertension. EVL is effective in controlling variceal hemorrhage in children with portal hypertension, regardless of etiology. The complication rate is low, and EVL is an acceptable and perhaps preferable alternative to EVS in children with esophageal varices.

Penetrating hepatic trauma in children: operating room or not?

Nonoperative management has become widely accepted as the standard of care for patients with blunt hepatic trauma. Recent studies among adults have supported the use of nonoperative management of selective penetrating wounds to the hepatic bed in stable patients. The therapeutic management of children with penetrating injuries to the hepatic bed were evaluated to ascertain whether nonoperative management was a reasonable consideration in their care. The database of the National Pediatric Trauma Registry (NPTR) was reviewed for the period 1985-1994. ICD-9 codes 864.00 to 864.10 were used to select injury site, diagnosis, and, combined with Current Procedural Terminology (CPT) code data, to ascertain therapeutic interventions. The NPTR is a compilation of data from 61 pediatric trauma centers, currently held at Tufts University. The charts of 29,000 children were reviewed; of these, 1,147 sustained hepatic injuries, 132 (12%) of whom had a penetrating injury. The mechanism of injury was gunshot wound in 100 patients (76%) and stab wound in 32 (24%). The mean age of the children who had a penetrating injury was 12.7 years (range, in utero to 19 years). Six children were managed nonoperatively (5%), and 20 (15%) had negative laparotomy findings. Overall, 106 children sustained additional injuries that required surgical repair. There were 50 hollow viscous injury repair, 19 diaphragmatic repairs, 5 nephrectomies, 4 splenectomies, 4 pancreatic resections, and 43 significant hepatic repairs. The overall mortality rate was 9.8% (13 deaths). Nine of these patients died within 24 hours of injury. These data indicate that penetrating injury to the hepatic bed in children is associated with a high percentage of other organ injuries that require surgical intervention. This seems to be in direct contrast with the findings for adults, for whom the hepatic mass appears protective because of its larger size. The close anatomic proximity of the organs in a child's abdomen appears to make surgical intervention necessary for the majority of children with penetrating injury to the hepatic bed, and indicates that this approach should remain the standard of care for pediatric patients.

The intussusception antireflux valve is ineffective in preventing cholangitis in biliary atresia.

Cholangitis is the most common complication after portoenterostomy for biliary atresia. The construction of an intussusception valve in the Roux-en-Y limb of the portoenterostomy has been advocated as a means to ameliorate this complication. The authors reviewed the records of children who underwent portoenterostomy to assess the incidence and severity of cholangitis, as well as outcome. The children were divided into two groups according to whether they did not have (group I) or did have (group II) an antireflux valve in the Roux limb of the bilioenteric conduit. There were 19 children in each group. There were no significant differences between the groups with respect to age at time of portoenterostomy or length of follow-up (Table 1). Nine group I patients are alive and well; five died and five have had or are awaiting transplantation. In group II, 10 patients are alive and well, eight have had transplantation, and one is awaiting transplantation. Outcome with respect to death or the need for liver transplantation because of progressive hepatic failure is not different between the groups (P = 1.0, Fisher's 2 x 2). The incidence of cholangitis was evaluated by comparing the average number of episodes of cholangitis during the follow-up period, the number of episodes per year, and the number of episodes in the first postoperative year (when this complication is most prevalent). Analysis of the data showed no difference in incidence between those with valved and nonvalved biliary conduits. The severity of cholangitis, judged by total length of antibiotic treatment, did not differ between the groups. It appears that the presence of an intussusception valve in the Roux-en-Y biliary conduit does not affect the incidence of cholangitis or the outcome after portoenterostomy, over short-term follow-up.

Laparoscopic thal fundoplication with gastrostomy in children.

A technique was developed to adapt the Thal fundoplication to the laparoscopic approach. Modifications include tying an umbilical tape (as a loop) around the esophagus for retraction, interrupted fundoplication sutures, and extracorporeal gastrostomy through a trocar site. This technique was completed successfully in 10 pediatric patients.

Recurrent appendicitis after initial conservative management of appendiceal abscess.

Therapy for children with appendiceal abscess remains controversial. The authors present two such cases initially treated conservatively, without interval appendectomy, that later had recurrent appendicitis. An 8-year-old boy presented with fever, abdominal pain, and a right-lower-quadrant abscess (noted by ultrasonography). During laparotomy, the abscess was drained and the appendix was not found. He was lost to follow-up but returned 2 1/2 years later with perforated appendicitis. An appendectomy was performed, and image-guided drainage of a postoperative abscess was required. A 10-year-old girl presented with fever and right-lower-quadrant pain. Computed tomography showed a multiloculated mass. During laparotomy, the cecum was found to be densely adherent to the pelvic organs and bowel, so the surrounding abscess was drained. Interval appendectomy was refused. The patient returned 8 months later with recurrent acute appendicitis and an appendiceal abscess requiring appendectomy and drainage. Although initial drainage alone of appendiceal abscess is efficacious, the authors strongly advocate interval appendectomy as a critical component of the complete management of this entity.

Nonoperative treatment of a major hepatic injury in a hemophiliac.

Selective nonoperative management of hepatic injuries from blunt trauma has become an accepted practice over the past 10 years. A case of nonoperative management of a major hepatic injury in a person with Hemophilia A is reported. Treatment with aggressive blood component therapy resulted in a successful outcome.

Patterns of splenic injuries seen in skiers.

Splenic rupture secondary to skiing appears to fall into two distinct epidemiological patterns: high-speed impact with stationary objects and simple falls (mogul injury). Of 18 splenic injuries seen at a referral hospital over 12 years, six were high-speed collisions with trees, lift towers or other solid objects. Twelve were low-speed falls impacting on moguls, the ski trail or low-speed impact with a trailside object (stump or rock). Those who sustained low-speed injuries frequently skied down the mountain afterwards without assistance (8/12), and had no other significant concomitant injuries other than minor renal contusions compared with the collision group (P < 0.005). The rate of splenic salvage was also higher in this group than in the collision group (68 per cent vs 17 per cent). The six high-speed collision splenic injury victims were all transported down the mountain by toboggan, and all had significant associated injuries. The incidence of concomitant renal injuries with splenic injuries in both groups was higher than in other reported series (10 of 18 patients). Some of those who skied down the mountain themselves sought medical attention only when they experienced haematuria. There were no significant differences in the length of stay in hospital, or intensive care units (ICU), or transfusion requirements or complications between groups. It is suggested that those who ski down the mountain themselves and present in a delayed fashion to medical/first aid facilities may still have serious abdominal injury but have a potentially higher rate of spleen salvage.

Improved outcome utilizing spinal anesthesia in high-risk infants.

The development of apnea following general anesthesia in high-risk infants (less than 60 weeks postconceptual age) has been reported up to 37%, prompting the routine admission of these children following minor surgical procedures. One hundred forty high-risk infants (American Society of Anesthesiologists category greater than or equal to 2) were prospectively evaluated after undergoing surgical procedures normally performed as outpatients in low-risk babies. All patients had spinal anesthesia for their operations. The mean gestational age for these infants was 30.8 +/- 3.7 weeks (minimum, 24 weeks) with a mean birth weight of 1,466.0 +/- 638.8 g. The mean postconceptual age and weight at the time of surgery were 44.8 +/- 7.8 weeks and 3,336 +/- 1,242 g, respectively. Difficulty in administering the spinal anesthetic occurred in 6 cases (4.2%). Postoperative complications occurred in 5 children (3.8%). They were: postoperative fever (2), transient bradycardia (2), and apnea (1). The four cases of postoperative fever and bradycardia were insignificant and required no medical intervention. The single case of apnea occurred in a premature infant who received a supplemental dose of intravenous midazolam. Length of operation in these cases ranged from 15 minutes to 95 minutes (mean, 53 minutes), with two incidents of inadequate anesthesia occurring in this cohort. Mean duration of anesthesia was 146 minutes (range, 50 to 240 minutes) and was directly dependent on dosage administration of the agents. These data indicate that the use of spinal anesthesia in high-risk infants is safe and effective for surgical procedures generally performed as outpatients (3.0% minor complication rate, 0.8% major complication rate).(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of granulocyte colony-stimulating factor (G-CSF) upon burn-induced defective neutrophil chemotaxis.

Severe thermal injury results in impairment of granulocyte production and function. The ability to improve the functional capacity of neutrophils could contribute to a reduced morbidity and mortality from sepsis following thermal injury. Previous studies from this laboratory have shown that rhG-CSF increases the number of femoral marrow granulocyte progenitor cells and circulating neutrophils as well as the survival rate following burn wound infection. The studies reported here examine the effect of in-vivo administration of rhG-CSF on neutrophil chemotaxis following a burn injury and also following superimposed Pseudomonas burn wound sepsis in mice. Casein-elicited peritoneal neutrophils were harvested 72 hours after burn injury and 24 hours after infection. Chemotaxis was assessed using microchemotaxis chambers and 10(-5) M fMet-Phe as a chemoattractant. The number of neutrophils that migrated into the filter was used as an index of directed chemotaxis. Burn injury resulted in depressed chemotaxis compared with sham or sham/G-CSF-treated animals (p less than 0.05). Administration of rhG-CSF to burned animals resulted in a level of neutrophil chemotaxis comparable with that in control animals. The presence of a burn wound infection caused no further impairment of chemotaxis. Administration of rhG-CSF to animals with a burn wound infection resulted in improved chemotaxis compared with sham, burned, and burned/infected animals. The beneficial effect of G-CSF following burn wound infections from this and previous studies appears to be a combination of expanded numbers of myeloid elements and preservation of their function.