NOTES for the management of an intra-abdominal abscess: transcolonic peritonoscopy and abscess drainage in a canine model.

BACKGROUND: We studied natural orifice transcolonic drainage of intra-abdominal abscesses in a canine survival model to evaluate the difficulty of peritonoscopy and abscess drainage and the reliability of endoluminal colotomy closure. METHODS: We placed a 7 cm nonsterile saline-filled latex balloon intra-abdominally to mimic or induce an abscess or inflammatory mass. Seven days later, we advanced a single-channel endoscope transanally into the sigmoid colon of the animal, made a colotomy and then advanced the endoscope intraperitoneally. We evacuated the identified abscess and placed a drain transabdominally. We closed the colotomy endoluminally with a tissue approximation system using 2 polypropylene sutures attached to metal T-bars. Two weeks later, we evaluated the colotomy closure at laparotomy. RESULTS: We studied 12 dogs: 8 had subphrenic balloon implants and 4 had interbowel loop implants. Eleven survived and underwent transcolonic peritonoscopy; we identified the "abscess" in 9. The colotomy was successfully closed in 10 of 11 dogs. Although abscesses were easily identified, the overall difficulty of the peritonoscopy was moderate to severe. One dog required colotomy closure via laparotomy, while 9 had successful endoluminal closure. After colotomy closure, 8 animals survived for 2 weeks (study end point) without surgical complications, sepsis or localized abdominal infections. On postmortem examination, all closures were intact without any adjacent organ damage or procedure-related complications. CONCLUSION: Natural orifice transluminal endoscopic surgery provides a novel alternative to treating intra-abdominal pathology. It is technically feasible to perform endoscopic transcolonic peritonoscopy and drainage of an intra-abdominal abscess with reliable closure of the colotomy in a canine experimental model.

CONTEXTE: Nous avons étudié le drainage transcolique par voie naturelle d'abcès intraabdominaux dans un modèle canin de survie afin d'évaluer la difficulté de la péritonoscopie et du drainage des abcès, ainsi que la fiabilité de la fermeture endoluminale de la colotomie. MÉTHODES: Nous avons inséré un ballonnet de latex de 7 cm non stérile empli de solution physiologique par voie intra-abdominale pour simuler ou induire un abcès ou une masse inflammatoire. Sept jours plus tard, nous avons introduit un endoscopeà simple canal par voie transanale jusqu'au sigmoïde de l'animal, procédé à une colotomie et ensuite poussé l'endoscope dans le péritoine. Nous avons vidé l'abcès observé et placé un drain par voie transabdominale. Nous avons ensuite procédé à une fermeture endoluminale de la colotomie avec un système de rapprochement tissulaire utilisant 2 sutures de polypropylène fixées à des pièces métalliques en T. Deux semaines plus tard, nous avons évalué la fermeture de la colotomie par laparotomie. RÉSULTANTS: Notre étude a porté sur 12 chiens : 8 avaient un ballonnet implanté au niveau sous-phrénique et 4, entre les anses intestinales. Onze ont survécu et ont subi la péritonoscopie transcolique; nous avons retracé « l'abcès ¼ chez 9 d'entre eux. La colotomie a été refermée avec succès chez 10 chiens sur 11. Même s'il a été facile de retracer les abcès, la difficulté globale de la péritonoscopie a été jugée de modéréeà marquée. Un chien a eu besoin d'une fermeture de colotomie par laparotomie, tandis que la fermeture endoluminale a réussi chez 9 animaux. Après la fermeture de la colotomie, 8 chiens ont survécu 2 semaines (fin de l'étude) sans complications chirurgicales, sepsis ni infections abdominales localisées. À l'autopsie, toutes les fermeturesétaient intactes, sans atteinte aux organes adjacents ni complications des suites de l'intervention. CONCLUSIONS: La chirurgie endoscopique transluminale par voie naturelle offre une solution de rechange pour le traitement des pathologies intra-abdominales. Il est possible au plan technique de réaliser une péritonoscopie transcolique endoscopique et de drainer un abcès intra-abdominal avec fermeture fiable de la colotomie dans un modèle expérimental chez le chien.

Emotional intelligence and the relationship to resident performance: a multi-institutional study.

STUDY OBJECTIVE: To test the hypothesis that emotional intelligence, as measured by a BarOn Emotional Quotient Inventory (EQ-i), the 125-item version personal inventory (EQ-i:125), correlates with resident performance. DESIGN: Survey (personal inventory) instrument. SETTING: Five U.S. academic anesthesiology residency programs. PARTICIPANTS: Postgraduate year (PGY) 2, 3, and 4 residents enrolled in university-based anesthesiology residency programs. MEASUREMENTS: Residents confidentially completed the BarOn EQ-i:125 personal inventory. The deidentified resident evaluations were sent to the principal investigator of a separate data collection study for data analysis. Data collected from the inventory were correlated with daily evaluations of the residents by residency program faculty. Results of the individual BarOn EQ-i:125 and daily faculty evaluations of the residents were compiled and analyzed. MAIN RESULTS: Univariate correlation analysis and multivariate canonical analysis showed that some aspects of the BarOn EQ-i:125 were significantly correlated with, and likely to be predictors of, resident performance. CONCLUSIONS: Emotional intelligence, as measured by the BarOn EQ-i personal inventory, has considerable promise as an independent indicator of performance as an anesthesiology resident.

Successful management of gastrojejunal strictures after gastric bypass: is timing important?

BACKGROUND: Endoscopic balloon dilation is an effective treatment of gastrojejunal (GJ) strictures after Roux-en-Y gastric bypass (RYGB), although its success might depend on the point at which they occur postoperatively. We hypothesized that "late" strictures (≥90 d after RYGB) might be less amenable to balloon dilations than "early" strictures occurring within 90 days postoperatively. METHODS: A review of a prospectively maintained database at a bariatric center was conducted to identify all patients who underwent upper endoscopy (UE) for investigation of gastrointestinal symptoms after RYGB. Those who were diagnosed with a GJ anastomotic stricture at endoscopy were selected for additional evaluation. The patients were classified into 1 of 3 groups, according to the point at which they presented with stricture symptoms (group 1, 0-90 d after RYGB; group 2, 91-365 d after RYGB; and group 3, >1 yr after RYGB). All strictures were dilated using through-the-scope controlled radial expansion balloons. RESULTS: From July 2006 to July 2009, 929 RYGB procedures were performed in our bariatric unit. Our surgical endoscopy team performs approximately 1500 UE investigations annually. Most investigations were for preoperative assessment of bariatric patients; however, a proportion is indicated for the investigation of postoperative weight regain and complications of foregut surgery, as well as endoluminal surgery. In the present study period, 591 gastric bypass patients underwent UE for investigation of gastrointestinal symptoms postoperatively. In total, 72 patients were diagnosed with a symptomatic GJ anastomotic stricture and underwent balloon dilation. Almost two thirds (63.9%) of the dilations were performed within 90 days after RYGB; 98% of these "early" strictures resolved with dilation. In comparison, of the "late" strictures, only 61% (16 of 26 patients) resolved and 38.5% (n = 10) required revisional surgery for additional management. CONCLUSION: Endoscopic balloon dilation is effective in treating early GJ strictures after RYGB. Late strictures are less amenable to endoscopic dilation and often require revisional surgery. Patients presenting with upper gastrointestinal symptoms after RYGB warrant early investigation with UE to investigate for a GJ stricture, which if present, should be promptly dilated.

Pancreatic islet isolation after gastric bypass in a rat model: technique and initial results for a promising research tool.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) affords a high remission rate of type 2 diabetes mellitus among morbidly obese diabetic patients. We report the use of the isolated islet technique to assess pancreatic function and glucoregulatory mechanisms after RYGB surgery. METHODS: A total of 15 adult, male, Sprague Dawley diet-induced obese rats were randomly divided into 3 experimental groups: sham, RYGB, and pair-fed, with 5 rats in each group. The body weight was measured at baseline and every week for 4 weeks. Pancreatic islet function was assessed in vitro according to the amount of insulin secreted from isolated islets incubated in 2 mM and 20 mM glucose for 1 hour at 37 °C. Fasting plasma glucose, insulin, glucagon-like peptide-1, PYY3-36, and glucose-dependent insulinotropic peptide were measured at baseline and 28 days after surgery. RESULTS: The baseline body weight was 917 ± 61, 831 ± 42, and 927 ± 43 g for the sham, RYGB, and pair-fed groups, respectively. The RYGB group lost 32% body weight compared with 16% for the sham and 24% for the pair-fed groups. Glucose-stimulated insulin secretion from the isolated islets in the RYGB group was greater than in the comparison groups (P = .04) at 4 weeks after surgery. Fasting plasma glucagon-like peptide-1 and PYY3-36 were significantly increased at 4 weeks in the RYGB group. CONCLUSION: Islet isolation and stimulation in the present animal model was feasible, affords a direct measurement of pancreatic islet function, and might provide a useful tool to study the effects of RYGB on pancreatic function and the relationship between islet cell function and incretin production after bariatric surgery.

Pre-Lap-Band group education in Medicaid population: does it really make a difference?

BACKGROUND: The effect of group education classes before a Lap-Band procedure has not been well defined. We hypothesized that in a Medicaid population, the completion of a standardized 12-week multidisciplinary preoperative program (SMPP) would significantly improve the preoperative and early postoperative weight loss. All procedures were performed at a University-affiliated community hospital from 2006 to 2007. METHODS: A prospectively collected database of 292 patients who underwent Lap-Band placement was retrospectively reviewed. All patients in the study cohort were encouraged to participate in the SMPP, which included medical, psychological, and nutritional interventions. The patients were divided into 2 groups according to their participation in the SMPP program: SMPP compliant and non-SMPP compliant. The postoperative weight loss of these 2 groups was then compared using the general linear models for repeated measures statistical analysis. RESULTS: No significant difference was found in the mean baseline excess body weight between the 2 groups (74 +/- 20 kg in the SMPP-compliant and 76 +/- 20 kg in the non-SMPP-compliant participants). The mean baseline body mass index (47 +/- 7 versus 48 +/- 72 kg/m(2) for the SMPP-compliant and non-SMPP-compliant participants) was also similar in the 2 groups. The postoperative follow-up rate was 94.5% at 1 month, 72.3% at 6 months, and 52.7% at 12 months. The excess weight loss was significantly greater in the SMPP compliant group than in the noncompliant group during the observed 12-month follow-up period (P = .04, by general linear models for repeated measures). CONCLUSION: In a Medicaid population, implementation of an intensive preoperative SMPP resulted in a significant improvement in the short-term weight loss after Lap-Band placement.

Emotional intelligence and its correlation to performance as a resident: a preliminary study.

STUDY OBJECTIVE: To test the hypothesis that emotional intelligence, as measured by the Bar-On Emotional Quotient Inventory (EQ-I) 125 (Multi Health Systems, Toronto, Ontario, Canada) personal inventory, would correlate with resident performance. DESIGN: Prospective survey. SETTING: University-affiliated, multiinstitutional anesthesiology residency program. PARTICIPANTS: Current clinical anesthesiology years one to three (PGY 2-4) anesthesiology residents enrolled in the University of Pittsburgh Anesthesiology Residency Program. MEASUREMENTS: Participants confidentially completed the Bar-On EQ-I 125 survey. Results of the individual EQ-I 125 and daily evaluations by the faculty of the residency program were compiled and analyzed. MAIN RESULTS: There was no positive correlation between any facet of emotional intelligence and resident performance. There was statistically significant negative correlation (-0.40; P < 0.05) between assertiveness and the "American Board of Anesthesiology essential attributes" component of the resident evaluation. CONCLUSIONS: Emotional intelligence, as measured by the Bar-On EQ-I personal inventory, does not strongly correlate to resident performance as defined at the University of Pittsburgh.

Presentation of dapsone-induced methemoglobinemia in a patient status post small bowel transplant.

Methemoglobinemia, an uncommon hemoglobinopathy, affects oxygen transport, causing tissue hypoxia. In the perioperative period, methemoglobinemia is often overlooked as a cause of low oxygen saturation, often mistaken for the more common causes of hypoxia, such as atelectasis, pulmonary edema, or pulmonary embolus, among other causes of respiratory failure. Most cases of methemoglobinemia in the perioperative period are precipitated by local anesthetics, especially benzocaine. Dapsone, a sulfone antibiotic, is used for prophylaxis against Pneumocystis carinii pneumonia in immunosuppressed patients. It is commonly used in organ transplant patients, especially those intolerant to sulfa. With the expansion of organ transplantation and improved long-term survival of these patients, presentation of status post organ transplant patients for surgery will inevitably increase. We report a case of dapsone-induced methemoglobinemia observed in a status post small bowel transplant patient in the postanesthesia care unit.

The resident application process and its correlation to future performance as a resident.

Many authors have attempted to determine predictors for success within a residency program. There is very little agreement about what is useful. We hypothesized that our residency selection process is effective in determining which resident applicants would be most likely to excel in our program. To test this hypothesis, we reviewed the scores that applicants received after their interview day to determine if there was a correlation with any measures used to evaluate residents once they entered residency training. Our results determined that the score given to an applicant fails to correlate with any of the areas that are evaluated throughout their residency. The only statistically significant correlation was between the scores assigned by the selection committee to applicants and the applicant scores on their first year in training examination. We concluded that our residency selection process score does not accurately predict which applicants will excel in our program.