Technical assessment of porcine enteroenterostomy performed with ZEUS robotic technology.

BACKGROUND/PURPOSE: Limitations of minimally invasive pediatric surgery include the inability to perform precise anastomoses of 2 to 15 mm. Robotic technology facilitates the performance of endoscopic microsurgical procedures. This study examined the technical feasibility of performing an enteroenterostomy in piglets utilizing ZEUS robotic technology. METHODS: Ten piglets (6.5 to 8.5 kg) underwent enteroenterostomy. Standard laparoscopic techniques were used in the control group (n = 5), and ZEUS robotic technology was used in the experimental group (n = 5). AESOP controlled the camera in both groups. Anesthesia time; surgery time; robotic set-up time; and anastomotic time, patency, diameter, and integrity were compared. RESULTS: No statistical difference existed between the means of the control and experimental groups for anesthesia time (176.0 v 154.0 minute; P =.63), surgery time (143.0 v 139.2 minute; P =.92), anastomosis time (109.4 v 93.0 minutes; P =.56), AESOP set-up time (4.2 v 7.0 minutes; P =.51), and anastomotic diameter (7.062 v 7.362 mm; P =.62). All anastomoses were patent without narrowing. The ZEUS cases averaged 14 minutes faster than the standard laparoscopic cases, even with the ZEUS set-up time included. CONCLUSIONS: These data supports the hypothesis that robotic-assisted enteroenterostomy is technically feasible. ZEUS robotic technology will potentially play an important role in expanding the applications of minimally invasive pediatric surgery.

An integrated model for measuring management performance.

A model of organizational performance measurement that compels attention to the proper balance among quality, cost, and access; takes into account patient perceptions; produces clear targets for continual quality improvement (CQI); yields easily understood graphical displays; and captures health care organizations in simultaneous operation across the functions of cost, quality, and access was designed for the 22 medical treatment facilities of the Strategic Air Command. Such a tool provides practitioners, payers, and patients a range of information--from systemwide, facility, clinical service, and practitioner-specific insights on current performance to resource forecasts and easily understood targets for CQI. This case study shows that integrated performance modeling may be useful in examining many health management and reform issues.

The impact of dedicated physician staffing on patient flow and quality assurance parameters in an Air Force emergency department.

A retrospective audit of 17,028 emergency charts at USAF Medical Center, Scott was performed over two time periods to compare patient waiting times and selected quality assurance parameters with two methods of physician staffing. Phase 1 consisted of 4 months when the Emergency Department (ED) was manned with five physicians assigned only to that department. Non-departmental physicians supplemented the full-time staff. Phase 2 was the corresponding 4 months the following year when the ED was staffed with six emergency physicians, and non-emergency physician coverage was minimal. The difference in daily census between the two periods of time was not statistically significant. The time required to be seen by a physician decreased from an average of 25.6 minutes per patient in phase 1 to 13.7 minutes per patient in phase 2. Time to disposition also decreased from 71.9 minutes per patient in phase 1 to 59.5 minutes per patient in phase 2. In the second phase the number of "positive" x-ray findings increased, while the number of incomplete charts and patients who left without being seen by a physician diminished.

A technique for long term continent gastrostomy.

The use of the continent gastrostomy described herein offers several advantages: 1, the elimination of an indwelling catheter; 2, prevention of soiling at skin level; 3, long term access to the normal gastrointestinal track for alimentation without fear of tube erosion; 4, little compromise to gastric volume, and 5, ease of stoma care. We recommend this operation in instances when long term tube feedings are indicated either because of damage to the central nervous system or as a palliative treatment for patients with higher obstructing gastrointestinal malignant disease. The procedure may also be useful for patients in whom esophagogastric continuity has been interrupted (surgically or traumatically) and in whom reconstruction of the gastrointestinal tract would not seem feasible within a three to six month interval.

Evaluation of various nutritional supplements in the prevention of stress-induced gastric ulcers in the rat.

We studied the effectiveness of various nutritional supplements in preventing stress-induced gastric ulcers in rats. Male rats were restrained on a board, divided into nine groups and orogastrically infused with one of four commercial nutritional supplements--25 per cent glucose solution, normal saline solution or antacids. The other groups received either cimetidine or no treatment. The rats, in this study, were sacrificed at the end of four hours, and all ulcers were counted. Any solution providing calories, including 25 per cent glucose solution, afforded significant protection against ulceration. While the antacids were better than no treatment, they were significantly worse than any nutritional supplement. It appears to be that luminal substrates markedly increase the ability of the gastric mucosa of the rat to resist ulceration.

The aviator after Nissen repair: gas bloat and other perils.

The postoperative experiences of a high-performance pilot who underwent Nissen fundoplication for reflux esophagitis illustrate two important points concerning return to flying duties. Both the gas bloat syndrome and obstructive phenomena are potential sequelae to surgery. Both have obvious implications for flight personnel. A logical approach for flight medical officers is presented.

Total colectomy with mucosal protectomy and ileoanal anastomosis--an important surgical option in the aviator with premalignant disease of the colon.

Total proctocolectomy with cutaneous ileostomy has been the standard therapy for many years for premalignant mucosal diseases of the colon, such as ulcerative colitis and familial polyposis. While this procedure relieves the patient of the risk of malignancy, it leaves him with the problem of the management of the ileostomy as well as exposing him to the risk of damage to the nerve supply of the bladder and genitalia during the dissection. Within the military population, the ileostomy is a particularly devastating problem as it disqualifies the individual from worldwide duty and requires him to meet a Medical Evaluation Board for discharge from the service. Over the last several years, total colectomy with mucosal proctectomy and ileoanal anastomosis (TCMPIA) has emerged as a viable surgical alternative in these conditions. The benefits of this procedure in the military population are multiple. It allows the individual to continue on active duty, fulfilling his desire to pursue his career as well as keeping the position filled for the military. The time and cost of a medical board are avoided, the military's investment in the individual's training is protected, and the need to train a new individual for the position is avoided.

A prospective randomized study of drained and undrained cholecystectomies.

One hundred twenty-three patients undergoing elective cholecystectomy at USAF Medical Center Keesler were studied in a prospective randomized manner to determine the differences in morbidity and mortality following drained and undrained cholecystectomies. The groups were compared for differences in mortality, wound infection, postoperative fever, and length of hospitalization. One death occurred due to an unrelated cause in an undrained patient. Three per cent of the undrained group developed wound infections as compared to five per cent in the drained group. This was not statistically significant. A significant difference occurred in postoperative fever between the drained (58%) and undrained (30%) groups. Postoperative hospitalization was also significantly shorter in the undrained group. This study suggests that drainage following elective cholecystectomy is not only unnecessary, but may add to postoperative morbidity and length of hospitalization.

The Hubbard tank as an adjunct to drainage in overwhelming intra-abdominal sepsis.

Open drainage of the peritoneal cavity for severe intra-abdominal sepsis has been gaining popularity. We had a patient whose overwhelming intra-abdominal infection did not respond to open drainage but was controlled by frequent immersion in a Hubbard tank. Use of the Hubbard tank should be considered in patients with uncontrolled intra-abdominal infection refractory to standard therapy.

Adjunctive antibiotic lavage in experimental peritonitis.

Lethal fecal peritonitis was created in 253 rats. The rats were then randomized to receive injections of saline solution or clindamycin and gentamicin. All rats received a saline solution lavage and were then further divided to receive a lavage with saline solution, gentamicin, clindamycin or cefoxitin. At the end of nine days, all surviving rats were sacrificed and examined for abscesses. All groups receiving clindamycin and gentamicin parenterally as well as those receiving a lavage with gentamicin or cefoxitin had a significantly better survival rate than did the control group. There was no difference in the number of abscesses in any group receiving antibiotics. Therefore, in this study, no benefit was achieved from an antibiotic lavage in rats receiving effective parenteral therapy.

Learning styles and the prospective surgeon.

There has recently been a surge of interest in medical education and specialty training. For many years, medical school curricula and residencies were guided mainly by tradition. Educators have now begun to reassess their methods in order to improve teaching efficiency and to better meet the needs of the trainee. Social psychologists and industry have led the way in mapping out the specific needs and learning styles of the adult student. Following this lead, many medical schools and training programs are adapting some of these techniques to evaluate the learning styles and needs of their students and residents. Learning style refers to the way one acquires and uses information. Application of the data may point out ways to better match the learning environment to the individual learning needs. This review outlines briefly the experimental learning theories of Kolb. It reviews current available data on learning styles in prospective surgeons and finally makes some correlation between these two fields of study. We hope to provide an introduction to learning style theories in relation to the surgical trainee that will stimulate further active pursuit of this important topic.

Hyperamylasemia due to poorly differentiated adenosquamous carcinoma of the ovary.

In a patient with poorly differentiated ovarian carcinoma, the symptomatology was mistaken for acute pancreatitis. A review of the pertinent literature argues in favor of the early use of amylase isoenzymes in patients whose history, objective signs, and routine diagnostic studies fail to disclose pancreatic disease.

Pancreatic retention cyst secondary to chronic pancreatitis. A cause of hemobilia.

We describe a 47-year-old male with chronic calcific pancreatitis who had a four-year history of occult gastrointestinal bleeding with three prior hospitalizations. At endoscopy on the fourth admission, hemobilia was identified. Arteriography showed a 3-cm-diameter dye blush in the head of the pancreas. A retention cyst had eroded into an adjacent artery, causing bleeding. A stone at the ampulla of Vater apparently served as a ball valve to prevent massive hemorrhage. We discuss the pathogenesis of hemobilia in chronic pancreatitis and suggested therapy.

Effects of carbenoxolone on gastric mucosal permeability and blood flow in the dog.

The effects of topical application of carbenoxolone at neutral and acidic pH were compared in exteriorized, chambered segments of canine gastric corpus. When dissolved in saline at pH 7.5 to 8.0, 0.25% carbenoxolone caused a rapid drop in gastric potential difference of 56 +/- 2 mv and greatly increased permeability to H+ ions. Blood flow, as measured by radioactive microspheres, was not changed by carbenoxolone treatment, but subsequent exposure to isotonic HC1 caused an abrupt rise in flow. Application of 0.25% carbenoxolone suspension in isotonic HC1 caused no change in potential difference, permeability, or blood flow. Neither carbenoxolone preparation had a significant effect on aspirin-induced H+ back-diffusion or injury.

Effects of parenteral alimentation on postoperative gastric function.

The effects of parenteral hyperalimentation on postoperative gastric function were studied in eleven patients undergoing abdominal aortic surgery. Positive nitrogen balance was achieved in hyperalimented patients. Hyperalimentation was found to augment gastric mucosal regeneration, allowing for more physiologic secretory patterns and the maintenance of the protective gastric mucosal mechanism.