Resident and faculty perceptions of a surgical residency program merger.

To evaluate resident and faculty perceptions of a residency merger process.Survey of faculty and residents of a recently merged general surgical residency. Nineteen separate program characteristics were evaluated via a numerical scoring system, and additional written commentary regarding dominant perceived benefits and detriments of the merger was solicited. Statistical significance was evaluated on numerically scored items by applying the Mann-Whitney U test to median values expressed with interquartile ranges, comparing resident and faculty responses.Scoring system responses from faculty and residents were generally similar. The merger was seen as neutral to positive in its impact on academic issues, but it had more negative effects on issues related to overall program atmosphere and morale. Statistically significant differences between resident and faculty responses were noted in 2 areas: teaching conference timing and overall program effectiveness in preparing for practice. Both of these areas were more favorably impacted by the merger from the residents' perspective, and more negatively as judged by the faculty (p < 0.05). Written commentary by both groups similarly emphasized areas of academic strengthening as a positive effect of the merger, and relationship and morale issues as being more negatively impacted.As reflected by resident and faculty perceptions, program mergers may provide opportunities to strengthen and enhance the academic and clinical foundation of residency. This may, however, occur at the expense of morale and relational issues, which may be negatively impacted by program administrative and geographic expansion.

Thrombosis risk in the trauma patient. Prevention and treatment.

Hypercoagulability is frequently seen in the trauma patients. Debate continues over the best method of prophylaxis, diagnosis, and treatment for the trauma patient. From experience with orthopedic and general surgery patients, much has been learned about prophylaxis and diagnosis, and as treatment protocols have been taken from internal medicine literature. Universal guidelines relating specifically to the trauma patient have not, however, been established. Overall, most of the literature suggests using LMWH for the prophylaxis of trauma patients. When LMWH is contraindicated, SCD should be used, with AVFP as a second choice. Surveillance screening for DVT remains controversial, but surveillance before transfer to extended care facilities has proven beneficial. Finally, when DVT is diagnosed, treatment should be initiated as soon as possible and should be continued until the DVT has resolved. Long-term anticoagulation therapy or use of caval filters may be necessary to prevent the morbidity of PE or thrombophlebitic syndrome.

TNP-470 antiangiogenic therapy for advanced murine neuroblastoma.

The finding that angiogenesis plays an important role in the progression and metastasis of malignant tumors has led to the development of several antiangiogenic drugs. The authors report here an examination of the effect of the antiangiogenic agent TNP-470 on the growth, metastases, and survival of two differing murine neuroblastoma cell lines, TBJ and C1300. We found that TNP-470 significantly reduced primary tumor volumes in mice injected with either cell line. In addition, antiangiogenic therapy significantly reduced the size of axillary lymph node metastases in both groups as well as decreased the size of liver metastases in mice receiving TBJ neuroblastoma. TNP-470 treatment also improved animal survival. These data suggest that antiangiogenic therapy retards the growth of primary and metastatic murine neuroblastoma. We speculate that antiangiogenic therapy may be a useful therapeutic modality in the treatment of advanced neuroblastoma once side effects and appropriate dosage requirements are determined.

Intestinal adaptation following massive small bowel resection in the mouse.

BACKGROUND: Transgenic mice represent powerful tools for studying the role of genes and their expression under multiple conditions, and they may provide a unique model for studies of intestinal adaptation after massive small bowel resection (SBR). This study characterized a successful model for SBR and intestinal adaptation in the mouse. STUDY DESIGN: Sham operation (bowel transection with reanastomosis) or SBR was performed on male C57BL/6 mice. A solid or liquid diet, various sizes of monofilament suture for the anastomosis, and resection of 50 or 75 percent of the proximal small intestine were studied. In other studies, intestinal adaptation was characterized as changes in intestinal wet weight, DNA, protein, villus height, crypt depth, and crypt cell proliferation rates at 12 hours, 24 hours, three days, and one, two, and four weeks after 50 percent SBR. RESULTS: Survival was significantly improved with a liquid diet (8 percent compared with 88 percent; p < .001) and modestly improved by using the smallest suture for anastomosis (60 percent for 7-0 compared with 88 percent for 9-0; p = not significant). Mice did not tolerate more than 50 percent SBR (16 percent survival rate for 75 percent SBR compared with 85 percent survival rate for 50 percent SBR; p < .01). Small bowel resection augmented ileal wet weight, DNA and protein content, villus height, crypt depth, and crypt-cell proliferation rates. CONCLUSIONS: Provision of a liquid diet, using a small suture for anastomosis, and resection of no more than 50 percent of the proximal small intestine are important for survival. This model will permit researchers using transgenic mice to better understand critical genes during intestinal adaptation after SBR.

Liver hemorrhage during laparotomy in patients with necrotizing enterocolitis.

UNLABELLED: Major liver hemorrhage (LH) without obvious iatrogenic injury was recently observed in several patients during operation for necrotizing enterocolitis (NEC). The purpose of this study was to determine the incidence and risk factors associated with the development of LH in patients with NEC. METHODS: The hospital charts of patients with NEC who underwent surgical exploration during a 5-year period (1989-1994) were reviewed. The patients in whom LH developed without obvious significant iatrogenic liver injury were compared with those who did not have LH. RESULTS: Eight of the 68 patients reviewed had LH. The survival rate for those with LH was 13%, compared with 88% for those without LH (P < .001). The patients with LH had a younger gestational age (28 +/- 3 weeks v 32 +/- 5 weeks) and a lower birth weight (1,262 +/- 489 g v 1,649 +/- 666 g); however, the differences were not significant. The patients with LH had significantly lower preoperative mean arterial blood pressure (35 +/- 1 mm Hg v 46 +/- 3 mm Hg; P < .001) and required greater fluid intake (272 +/- 28 mL/kg/d v 186 +/- 9 mL/kg/d; P < .01) for the 24 hours preceding surgery. CONCLUSION: LH is as an important and lethal complication associated with laparotomy in very small infants with NEC. The presence of hypotension and the administration of large amounts of volume in the preoperative period appear to be risk factors. Earlier surgical intervention and restoration of blood pressure using inotropic agents, once a particular level of fluid administration has been achieved, my be preventive.

Cecal-colic adult intussusception as a cause of intestinal obstruction in Central Africa.

During a 5-year experience in Central Africa, the most common cause of 78 adult intestinal obstructions was primary adult cecal-colic intussusception (n = 43; 55%). The symptom complex of colicky abdominal pain and obstipation was present in 100% of the patients with intussusception. Operative repair in 90% of patients consisted of simple reduction of the intussusceptum. There were no known recurrences. The etiology of adult cecal-colic intussusception is unknown. Patients typically present with a 3- to 4-day history of abdominal pain, obstipation, and usually a palpable mass. Treatment is surgical reduction. Right colectomy is reserved for intestinal gangrene. We treated 43 cases during a 5-year period with only one death.

The use of laparoscopy in the management of seat belt trauma in children.

Abdominal wall, hollow viscous, and spinal cord injuries are severe complications of two point seat belt restraints in children. Somatic abdominal wall pain can mask the presence of potentially life-threatening intraperitoneal injuries, false-positive peritoneal lavage can lead to unnecessary celiotomy, and CT scan can miss hollow viscous injury. All of these concerns point to the need for a more effective diagnostic modality. Laparoscopy may have a role in the diagnosis and management of lap belt-related hollow viscous and mesenteric injuries. The presence of either free peritoneal fluid or mesenteric thickening, seen on CT scan, associated with an seat belt-related abdominal wall contusion are criteria for diagnostic laparoscopy. Four patients, age 3 to 15, underwent laparoscopy. Diagnostic laparoscopy employed two additional laterally placed ports and extreme Trendelenburg and reverse Trendelenburg to facilitate the thorough examination of the small bowel. Injuries identified were a severely contused cecum, a contusion of the small bowel with associated mesenteric hematoma, transverse colon contusion and gastric perforation, and a small bowel contusion. No delayed reexplorations were required for missed injuries and there were no complications associated with laparoscopy. This experience suggests that laparoscopy may have a role in the diagnosis and management of seat belt trauma in children.

Traumatic pancreatic fistula in children: early management with a somatostatin analogue and drainage.

The management of a high-output pancreatic fistula is often difficult, and can be even more challenging in the pediatric patient. Octreotide acetate (OA) (Sandostatin, Sandoz, East Hanover, NJ) has served to facilitate the treatment of this difficult problem, but experience has been limited to adults. Somatostatin is a hormone that decreases the production of pancreatic exocrine and endocrine secretions. The use of the long-acting somatostatin analogue, OA, has reduced pancreatic fistula output and facilitated resolution of pancreatic fistulae in adults. This report summarizes the IV use of OA and external drainage in the complete resolution of high-output traumatic pancreatic fistulae in three pediatric patients. The treatment was well tolerated without side effects, and resulted in a dramatic decrease in the amount of fistula drainage within the first 24 to 48 h. OA can be safely administered IV (5-10 µg/kg per day) and is valuable in the management of traumatic pancreatic fistula in children.