A Cost-Effective Microfluidic Device to Teach the Principles of Electrophoresis and Electroosmosis.

Electrophoresis is integral to analytical and biochemistry experiences in undergraduate education; however, fundamental principles of the method are often taught in upper-level laboratories through hands-on experiences. A laboratory activity is reported that teaches the concepts of electrophoretic mobility and electroosmotic flow. A single reuseable instrument, called a mini-E, costs 37 USD and consists of a DC power supply, a voltmeter, platinum electrodes, and a chip cast in polydimethylsiloxane. This activity uses common reagents costing only 0.02 USD per student. Experiments are devised that allow students to investigate the properties of electrophoretic flow and electroosmotic flow by separating the two commonly used food dyeing agents Brilliant Blue FCF and Allura Red AC in vinegar and in a solution of ammonium hydroxide. A dark-purple mixture of these dyes is separated into red and blue bands that are easily visualized. The migration order of the dyes differs when the separation is performed under conditions of reversed polarity and suppressed electroosmotic flow (vinegar) compared to conditions of normal polarity and active electroosmotic flow (ammonium hydroxide). When delivered to chemistry majors, students had a significant gain in their ability to apply the concepts of electroosmosis and electrophoresis to predict analyte migration. Although this activity targets upper-level chemistry content, it can also be adapted for other laboratory experiences.

Psychoeducational and motivational treatment for low-weight Avoidant/Restrictive Food Intake Disorder (ARFID): Three case reports in school-aged children.

BACKGROUND: Individuals with Avoidant/Restrictive Food Intake Disorder (ARFID) experience restrictive or highly selective eating problems that interfere with growth and development. Despite the increasing number of referrals for ARFID, no evidence-based treatments exist. This compilation of case composites describes a novel manualized treatment, Psychoeducational and Motivational Treatment (PMT) for children with ARFID, focusing on exploring motivation to change eating behaviors. This approach is based on motivational non-directive psychotherapy models, psychoeducational interventions, and the usefulness of play to support psychotherapeutic learning in school-age children. CASE PRESENTATIONS: Three cases of children with ARFID treated using PMT are presented: a 7-year-old, a 10-year-old, and a 12-year-old. These cases illustrate how a clinician delivers PMT interventions in the context of developmental abilities and common comorbidities associated with ARFID. CONCLUSION: PMT is a promising therapy for ARFID in school-age children. Challenges and strategies are discussed, including ways to address obstacles such as young age, comorbidities, and use of the virtual environment.

Declining Military Surgical Cases and the Impact on Military Surgical Graduate Medical Education.

BACKGROUND: Several studies have indicated a decline in the number, types, and complexity of surgical procedures within military treatment facilities (MTFs). This study aims to determine what effect, if any, these downward trends have had on the relationship between the military health system (MHS) and surgical graduate medical education. METHODS: Graduating chief resident final ACGME case logs from 4 of thirteen military general surgery programs were evaluated from 2015 to 2020. The proportion of total cases performed by residents at military institutions were compared on a year over year basis. RESULTS: The proportion of cases performed within the military hospitals declined 3.27% each year between 2015 and 2020 (P < .0001) in 4 MTFs. All individual hospitals had significant declines in case volume except one (William Beaumont Army Medical Center) which increased 6.05% with each year, but also increased the number of MTF partnerships within its program (P < .0001). CONCLUSIONS: There has been a statistically significant decline over time in the proportion of cases logged by residents within the studied military treatment facilities. Investment into military hospitals to increase case numbers, case diversity, and complexity and/or acceptance of this gradual decline with greater shifting of educational workload onto civilian hospitals is required.

Status of robotic assisted surgery (RAS) and the effects of Coronavirus (COVID-19) on RAS in the Department of Defense (DoD).

The purpose of this study is to update the available literature with information on the current use of robotic assisted surgery (RAS) in the Department of Defense (DoD) compared to the civilian world, and how the coronavirus disease 2019 (COVID-19) pandemic impacted RAS in the DoD. A total of 9,979 RAS cases between 01st October 2017 and 31st December 2020 were reviewed from every DoD Military Treatment Facility (MTF) that meets our inclusion criteria and employs various models of da Vinci robotic surgical systems (Intuitive Surgical). Specialty, number, and facility were recorded for each case. These data were then compared to previously known trends about RAS use in the DoD as well as with civilian trends. Before COVID-19, the use of RAS had increased over time, but not at the same rate as in the civilian sector. General surgery cases constituted most RAS cases in both the DoD and the civilian sector. The arrival of COVID-19 in the United States significantly decreased the use of RAS in the DoD as well as in the civilian sector in all surgical specialties because it led to postponement or cancellation of many non-emergent surgical procedures. In conclusion, the use of RAS has continued to increase, and general surgery cases continue to constitute most of these cases. However, since the COVID-19 pandemic began, there was a significant decline in both DoD and civilian RAS cases, with a more pronounced decline in the DoD.

Clinical utilization of deployed military surgeons.

BACKGROUND: Combat casualty care has been shaped by the prolonged conflicts in Southwest Asia, namely Afghanistan, Iraq, and Syria. The utilization of surgeons in austere locations outside of Southwest Asia and its implication on skill retention and value have not been examined. This study hypothesizes that surgeon utilization is low in the African theater. This lack of activity is potentially damaging to surgical skill retention and patient care. METHODS: Military case logs of surgeons deployed to Africa under command of Special Operations Command Africa between January 1, 2016, and January 1, 2020, were examined. Cases were organized based on population served, general type of procedure, current procedural terminology codes, and location. RESULTS: Twenty deployment caseloads representing 74% of the deployments during the period were analyzed. In 3,294 days, 101 operations were performed, which included 45 on combat/terrorism related injuries and 19 on US personnel. East and West African deployments, combat, and noncombat zones, respectively, were compared. East Africa averaged 4.1 ± 3.8 operations per deployment, and West Africa, 7.3 ± 8.0 (p = 0.2434). In East Africa, 56.1% of total operations were related to combat/terrorism, compared with 29.6% of total operations in West Africa (p = 0.0077). West Africa had a significantly higher proportion of elective (p = 0.0002) and humanitarian cases (p = <0.0001). CONCLUSION: Surgical cases for military surgeons were uncommon in Africa. The low volumes have implications for skill retention, morale, and sustainability of military surgical end strength. Reduction in deployment lengths, deployment location adjustments, and/or skill retention strategies are required to ensure clinical peak performance and operational readiness. Failure to implement changes to current practices to optimize surgeon experience will likely decrease surgical readiness and could contribute to decreased retention of deployable military surgeons to support global operations. LEVEL OF EVIDENCE: Economic/decision, level III.

Current challenges in military trauma readiness: Insufficient relevant surgical case volumes in military treatment facilities.

BACKGROUND: The management of battlefield trauma requires a specific skill set, which is optimized by regular trauma experience. As military casualties from the prolonged conflicts in the Middle East decrease, challenges exist to maintain battlefield trauma readiness. Military surgeons must therefore depend on the Military Health System. The purpose of the study was to evaluate the frequency of surgical cases relevant to deployed combat casualty care performed at military treatment facilities (MTFs). METHODS: Combat casualty care relevant cases (CCC-RCs) were defined as emergent, open surgical cases in which the patient required a blood transfusion. Case logs from four military treatment centers with surgical residency training programs were used. Twenty-four months of case records between January 1, 2017, and January 1, 2019, were included to determine total numbers of CCC-RCs at each institution. The results were compared with San Antonio Military Medical Center's, the Department of Defense's only American College of Surgeons-verified level 1 trauma center. RESULTS: Fifty-one trauma/general surgeons and six vascular surgeons case logs were examined. Thirty (0.3%) of 10,529 cases performed by trauma/general and vascular surgeons over the 2-year study period were considered CCC-RCs. These results were in contrast to San Antonio Military Medical Center, which had a significantly higher proportion of CCC-RCs (113 of 320 cases, 35.3%, p < 0.0001). CONCLUSION: A cross-section of MTF surgical case complexity demonstrates a lack of cases considered to be CCC-RCs. At the MTFs evaluated, surgical case surrogates for combat trauma and combat casualty care is close to zero. These data are potentially representative of other military treatment centers, which focus on beneficiary care. For readiness purposes, MTFs that care primarily for Tricare beneficiaries without a significant trauma population should not be considered meaningful sources of CCC-RCs for trauma/general and vascular surgeons. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Examining Utility of Routine Splenic Flexure Mobilization during Colectomy and Impact on Anastomotic Complications.

BACKGROUND: Despite a lack of supporting data, routine splenic flexure mobilization (SFM) during colectomy has been thought to reduce anastomotic leak (AL). We evaluated the impact of SFM on outcomes in distal colectomy. STUDY DESIGN: The 2005-2016 NSQIP database identified 66,068 patients undergoing distal colectomy with anastomosis. Cohorts were stratified by addition of SFM. Postoperative outcomes were compared between groups. Regression analysis identified factors affecting odds of developing AL. RESULTS: SFM was performed in 27,475 patients (41.6%). There was no difference in overall complications between cases with SFM and those without (p = 0.55). SFM had longer operative times (220 min vs. 184 min; p < 0.0001). SFM was not associated with any difference in AL rate (3.6% vs. 3.7%; p = 0.86). Factors most associated with AL were lack of oral antibiotic preparation (OR 1.93; p < 0.001), chemotherapy (OR 1.91; p < 0.001), and weight loss (OR 1.68; p = 0.0005). Operative indication and approach did not affect leak. CONCLUSIONS: SFM in distal colectomy increased operative time without decreasing overall complications or AL. Routine splenic flexure mobilization may add risk without significant benefit.

Status of Robotic-Assisted Surgery (RAS) in the Department of Defense (DoD).

INTRODUCTION: Since inception of robotic-assisted surgery (RAS) in 1999, there has been an exponential rise in RAS in both number and complexity of surgical cases performed. The majority of these cases are gynecologic surgery in nature, with only a quarter of them labeled as general surgery. The purpose of this study is to determine if RAS in the Department of Defense (DoD) mirrors these trends. METHODS: A total of 6,204 RAS cases from across the DoD were reviewed between 01 January 2015 and 30 September 2017 from every Military Treatment Facility (MTF) that employs a robotic surgical device (various models of the da Vinci robotic surgical system by Intuitive Surgical). Specialty, number, and surgeon were recorded for each case. These end points were also examined for trends overtime and compared to similar civilian data. RESULTS: The number of MTFs performing robotic surgery and the number of cases performed increased significantly. An average of 373 cases per quarter-year were performed in 2015, 647 in 2016, and 708 in 2017. The number of RAS cases increased by about 10% every quarter-year during this time period. RAS was most commonly performed by general surgery in 10 of the 14 MTFs examined. CONCLUSIONS: MTFs implemented RAS much later than the civilian world. However, since its implementation, the frequency of RAS use has increased at a faster rate in the DoD than in the civilian world. Possible reasons for this are a younger pool of surgeons in the military and less demands on cost-effective productivity, allowing these younger surgeons to focus on emerging technology rather than maximizing surgical cost efficiency. General surgery constitutes the majority of RAS cases in the DoD. It is unclear why this difference from the civilian world exists.

Cancer vaccines in colon and rectal cancer over the last decade: lessons learned and future directions.

INTRODUCTION: Great advances have been made in screening for and treatment of colorectal cancer (CRC), but recurrence rates remain high and additional therapies are needed. There is great excitement around the field of immunotherapy and many attempts have been made to bring immunotherapy to CRC through a cancer vaccine. Areas covered: This is a detailed review of the last decade's significant CRC vaccine trials. Expert commentary: Monotherapy with a CRC vaccine is likely best suited for adjuvant therapy in disease free patients. Vaccine therapy elicits crucial tumor infiltrating lymphocytes, which are lacking in microsatellite-stable tumors, and therefore may be better suited for these patients. The combination of CRC vaccines with checkpoint inhibitors may unlock the potential of immunotherapy for a much broader range of patients. Future studies should focus on vaccine monotherapy in correctly selected patients and combination therapy in more advanced disease.

Colonoscopy after Hinchey I and II left-sided diverticulitis: utility or futility?

BACKGROUND: Modern 64- to 128-slice computed tomography (CT) scanners have questioned the need for routine colonoscopy after hospital admission for presumed uncomplicated diverticulitis. METHODS: This is a retrospective review of all patients (>18 years) who underwent planned colonoscopy after admission for Hinchey I or II acute diverticulitis (January 2009 to January 2014). The findings on the final radiologist report were then correlated with the colonoscopy results. RESULTS: In total, 110 patients (mean age, 55.2 ± 16; 46.4% female) underwent a subsequent colonoscopy (median, 60 days) after admission for diverticulitis. Overall, 102 patients (92.7%) had CT findings consistent with definitive diverticulitis, 6 patients had a diagnosis suggestive of diverticulitis on CT scan, and 2 patients had masses on their admission CT scans. Within the group with definitive diverticulitis, follow-up colonoscopy identified diverticulosis in 99 (97.0%), whereas the other 3 had normal findings. Of the patients with CT scans suggestive of diverticulitis, follow-up colonoscopy showed 3 with diverticulosis, 2 with malignancies, and 1 with nonspecific inflammation. The reliability of CT scans for diverticulitis compared with colonoscopy was found to have a kappa = .829 (P < .001; 95% confidence interval, .629, 1.21). CONCLUSIONS: Follow-up colonoscopy should be performed when a CT scan suggests malignancy, nonspecific inflammatory findings, or the patient is otherwise due for routine screening or surveillance. In this study, there was no benefit of follow-up colonoscopy in patients with CT-confirmed diverticulitis in the absence of other concerning or indeterminate findings.

Fluorescence Angiography in Colorectal Resection.

BACKGROUND: Intraoperative laser fluorescence angiography is a relatively new tool that can be used by colorectal surgeons to ensure adequate perfusion to bowel that remains after resection. It has been used mostly to determine an appropriate point of transection of the proximal bowel, as well as to ensure perfusion after the anastomosis has been constructed. We propose a different use of the technology in complex cases to ensure the ability to safely transect a major vascular pedicle and to ensure that perfusion will remain adequate. OBJECTIVE: The purpose of this article is to describe a new use for fluorescence angiography technology. DESIGN: This is a technical note. SETTINGS: The work was conducted at a tertiary care military medical center. PATIENTS: Patients included individuals requiring oncologic colorectal resection where the status of 1 major vascular pedicle was unknown or impaired. MAIN OUTCOME MEASURES: We assessed perfusion after occlusion of a major vascular pedicle for the short term in hospital outcomes. RESULTS: Adequate studies were obtained, and perfusion was maintained in both patients. Oncologic resections were performed, and short-term outcomes were comparable with any individual undergoing these procedures. LIMITATIONS: This study was limited because it is early experience that was not performed in the setting of a scientific investigation. CONCLUSIONS: Application of intraoperative fluorescence angiography in this setting appears to be safe and may assist the surgeon in estimating reliable vascular perfusion in patients such as these who require oncologic colorectal resection.

Biomaterials in the treatment of anal fistula: hope or hype?

Anal fistula (AF) presents a chronic problem for patients and colorectal surgeons alike. Surgical treatment may result in impairment of continence and long-term risk of recurrence. Treatment options for AFs vary according to their location and complexity. The ideal approach should result in low recurrence rates and minimal impact on continence. New technical approaches involving biologically derived products such as biological mesh, fibrin glue, fistula plug, and stem cells have been applied in the treatment of AF to improve outcomes and decrease recurrence rates and the risk of fecal incontinence. In this review, we will highlight the current evidence and describe our personal experience with these novel approaches.

The weekend effect: does time of admission impact management and outcomes of small bowel obstruction?

AIMS: To determine whether day and time of admission influences the practice patterns of the admitting general surgeon and subsequent outcomes for patients diagnosed with small bowel obstruction. METHODS: A retrospective database review was carried out, covering patients admitted with the presumed diagnosis of partial small bowel obstruction from 2004-2011. RESULTS: A total of 404 patients met the inclusion criteria. One hundred and thirty-nine were admitted during the day, 93 at night and 172 on the weekend. Overall 30.2% of the patients were managed operatively with no significant difference between the groups (P = 0.89); however, of patients taken to the operating room, patients admitted during the day received operative intervention over 24 hours earlier than those admitted at a weekend, 0.79 days vs 1.90 days, respectively (P = 0.05). Overall mortality was low at 1.7%, with no difference noted between the groups (P = 0.35). Likewise there was no difference in morbidity rates between the three groups (P = 0.90). CONCLUSIONS: Despite a faster time to operative intervention in those patients admitted during the day, our study revealed that time of admission does not appear to correlate to patient outcome or mortality.

Future directions for the early detection of colorectal cancer recurrence.

Surgical resection remains a mainstay of treatment and is highly effective for localized colorectal cancer. However, ~30-40% of patients develop recurrence following surgery and 40-50% of recurrences are apparent within the first few years after initial surgical resection. Several variables factor into the ultimate outcome of these patients, including the extent of disease, tumor biology, and patient co-morbidities. Additionally, the time from initial treatment to the development of recurrence is strongly associated with overall survival, particularly in patients who recur within one year of their surgical resection. Current post-resection surveillance strategies involve physical examination, laboratory, endoscopic and imaging studies utilizing various high and low-intensity protocols. Ultimately, the goal is to detect recurrence as early as possible, and ideally in the asymptomatic localized phase, to allow initiation of treatment that may still result in cure. While current strategies have been effective, several efforts are evolving to improve our ability to identify recurrent disease at its earliest phase. Our aim with this article is to briefly review the options available and, more importantly, examine emerging and future options to assist in the early detection of colon and rectal cancer recurrence.

Mesenteric irritation as a means to prevent internal hernia formation after laparoscopic gastric bypass surgery.

INTRODUCTION: Internal hernias (IHs) occur more frequently in laparoscopic gastric bypass (LGB) surgery than in the classic open procedure. The incidence of small bowel obstruction after LGB ranges from 1.8% and 9.7%. Some have theorized that this occurs because of decreased adhesion formation. METHODS: The mesenteric irritation technique is performed after closure of the jejunojejunal mesenteric defect with a running 2-0 silk suture. A sponge is then rubbed against the closed visceral peritoneal mesentery until petechiae are visualized on the surface of the mesentery. RESULTS: In all, 338 LGBs were performed using the standard closure technique with an IH incidence of 5.3% (range 1.7% to 7.8%). When using the mesenteric irritation technique, 72 LGBs were performed with an IH rate of 1.4% (P = .13). CONCLUSIONS: Mesenteric irritation is a novel technique performed with minimal additional time and no additional equipment. This technique may prove beneficial in reducing the incidence of IHs.

Predictors of appendiceal perforation in an equal access system.

BACKGROUND: Discrepancies in socioeconomic factors have been associated with higher rates of perforated appendicitis. As an equal-access health care system theoretically removes these barriers, we aimed to determine if remaining differences in demographics, education, and pay result in disparate outcomes in the rate of perforated appendicitis. MATERIALS AND METHODS: All patients undergoing appendectomy for acute appendicitis (November 2004-October 2009) at a tertiary care equal access institution were categorized by demographics and perioperative data. Rank of the sponsor was used as a surrogate for economic status. A multivariate logistic regression model was performed to determine patient and clinical characteristics associated with perforated appendicitis. RESULTS: A total of 680 patients (mean age 30±16 y; 37% female) were included. The majority were Caucasian (56.4% [n=384]; African Americans 5.6% [n=38]; Asians 1.9% [n=13]; and other 48.9% [n=245]) and enlisted (87.2%). Overall, 6.4% presented with perforation, with rates of 6.6%, 5.8%, and 6.7% (P=0.96) for officers, enlisted soldiers, and contractors, respectively. There was no difference in perforation when stratified by junior or senior status for either officers or enlisted (9.3% junior versus 4.40% senior officers, P=0.273; 6.60% junior versus 5.50% senior enlisted, P=0.369). On multivariate analysis, parameters such as leukocytosis and temperature, as well as race and rank were not associated with perforation (P=0.7). Only age had a correlation, with individuals aged 66-75 y having higher perforation rates (odds ratio, 1.04; 95% confidence interval, 1.02-1.05; P<0.001). CONCLUSIONS: In an equal-access health care system, older age, not socioeconomic factors, correlated with increased appendiceal perforation rates.

Future directions for monitoring treatment response in colorectal cancer.

Treatment of advanced colon and rectal cancer has significantly evolved with the introduction of neoadjuvant chemoradiation therapy so much that, along with more effective chemotherapy regimens, surgery has been considered unnecessary among some institutions for select patients. The tumor response to these treatments has also improved and ultimately has been shown to have a direct effect on prognosis. Yet, the best way to monitor that response, whether clinically, radiologically, or with laboratory findings, remains controversial. The authors' aim is to briefly review the options available and, more importantly, examine emerging and future options to assist in monitoring treatment response in cases of locally advanced rectal cancer and metastatic colon cancer.

What is the real cost of an overnight stay after an ambulatory general surgical procedure?

INTRODUCTION: Outpatient surgery is performed widely throughout the Army Medical Command (MEDCOM). It is common practice throughout Medical Command to admit barracks dwelling active duty service members (ADSMs) undergoing ambulatory surgical procedures for overnight observation. We hypothesized that overnight observation of these individuals has not prevented adverse outcomes that would have otherwise occurred if the patient had been discharged to the barracks. METHODS: We reviewed the postoperative course of all ADSMs undergoing ambulatory surgery with subsequent overnight hospital stay because of primary barracks residence. Procedures included hernia repair, lipoma excisions, and pilonidal cystectomies. Inclusion criteria were ADSMs who stayed overnight purely on the basis of their military barracks residence. RESULTS: 145 patients met our inclusion criteria. Their mean age was 23 ± 3.2, 90.9% were males. The mean hospital length of stay was 24 ± 11.4 hours. There were four (2.78%) postoperative complications, three patients with postoperative urinary retention, and one patient with mild bleeding from a pilonidal excision site, all within 8 hours postoperatively. No adverse outcomes were noted during the period of their hospitalization. CONCLUSION: Barracks dwelling ADSMs do not have adverse outcomes during their inpatient observational hospitalization. An outpatient escort would be sufficient to ensure adequate observation.

An evaluation of colonoscopy surveillance guidelines: are we actually adhering to the guidelines?

BACKGROUND: National guidelines put forth by the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Gastroenterology provide recommendations regarding colorectal cancer screening and follow-up surveillance. Practice patterns may differ from these guidelines. This study analyzes the concordance between a tertiary equal access system and national guidelines for colorectal cancer and polyp surveillance. METHODS: We performed a retrospective database review of all patients at a single institution undergoing screening colonoscopy from 2010 to 2011. Patient demographics, indication for colonoscopy, pathologic findings, and follow-up recommendations documented by the provider were analyzed. Multivariate analysis was performed in an attempt to identify predictors of discordant recommendations. RESULTS: One thousand four hundred twenty patients were identified (mean age, 54.3 ± 7.7 years, 48.6% women). The gastroenterology service performed the majority of colonoscopies (87.2%) compared with the surgery service (11.6%). The major indications were routine screening (84.4%) and a strong family history of colorectal cancer (12.2%). The adenoma detection rate for the entire cohort was 27.4%. Other pathologic conditions identified included hyperplastic polyps (16%), lymphoid aggregates (3.5%), and invasive adenocarcinoma (0.1%). Overall, follow-up recommendations correlated with established guidelines in 97% of cases. By multivariate analysis, only the final pathologic finding of lymphoid aggregates was associated with discordant recommendations (odds ratio [OR], 4.62; 95% confidence interval [CI], 1.64 to 12.99; P = .004). When comparing discordant recommendations between specialties, there was a statistically significant difference between gastroenterology (1.6%) and surgery (7.6%) (P < .0001) providers; surgeons trended toward recommending earlier follow-up examinations (P = .37). CONCLUSIONS: Overall, surveillance recommendations correlated well with current national guidelines. Concordance rates were higher with gastroenterologists in this cohort. Alterations based on final pathologic examination and individual cases remain clinically important.