Surgery in practice and science最新文献

Introduction

In the aftermath of the United States Medical Licensing Examination (USMLE) Step 1 becoming pass/fail, research has become a more important component of residency applications. Time is a finite resource, and clinicians, both academic and private practice, struggle to balance research within their schedules. We aim to provide a model to produce impactful research efficiently.

Methods

We describe our experience in developing a modern-day research model that was developed to create a robust research program at our institution. A grassroots initiative of researchers, including academicians, a burn fellow, residents, and students, has become a research model that large academic institutions should leverage for efficiency and productivity.

Results

What began as one attending, one fellow, four medical students, and one burn center grew in several months to include over 170 students, a student organization, five fellows from varying specialties, seven residents, and 22 faculty members in 15 disciplines. In addition, our collaboration includes interdisciplinary research involving other institutional departments such as mathematics, medical education, biostatistics, industrial engineering, and computer engineering. Tenably, we have over 150 projects in the works, 22 publications, 47 podium presentations, 47 poster presentations, and over 150 approved IRB proposals, along with four grants— all in 16 months.

Discussion

As we move into the era of the ungraded medical student, the importance of research experience and productivity is rising. Academic institutions that adapt to this change in the medical education landscape have the opportunity to increase innovation and their institution's contributions to academic medicine while producing well-rounded graduates with skills vital to efficacious patient care.

Conclusion

This research model allows for interdisciplinary collaboration and efficient research productivity in large academic institutions. We aim to inspire other institutions to consider implementing a similar research model and continue to contribute to the innovation and advancement of medicine.

Background

The presence of image‑defined risk factors (IDRF) in neuroblastoma plays a large role in decision making for primary resection versus neoadjuvant chemotherapy. This study investigates how the number and type of IDRFs affect surgical outcomes for primary resection of neuroblastoma.

Materials and methods

A retrospective review was performed including patients diagnosed with neuroblastoma with at least one IDRF who underwent primary resection of their tumor between 2003 and 2017. Cross sectional imaging was reviewed by a single pediatric radiologist for determination of IDRFs. Surgical outcomes were compared by <5 versus ≥5 IDRFs and vascular or non‑vascular involvement.

Results

A total of 28 patients were included in the study, 18 with <5 IDRFs and 10 with ≥5 IDRFs. Fifteen patients had vascular involvement and 13 did not. Nine were adrenal, 6 were cervicothoracic, and 5 were abdominal non-adrenal. Patients with ≥5 IDRFs were found to have an increased rate of complications (40% vs 0%; p<0.01), operative time (318 vs 148 min; p<0.01), estimated blood loss (187 mL vs 45 mL; p<0.01), length of stay (9.6 vs 4.9 days; p<0.01), and hospital readmission (20% vs 0%; p = 0.04). No differences were found in degree of resection (p = 0.06). All complications occurred with vascular involvement IDRFs compared to non‑vascular IDRFs (27% vs 0%; p = 0.04).

Conclusion

The presence of ≥5 IDRFs and vascular involvement increases complications associated with primary resection of neuroblastoma. Our findings underscore the importance of neoadjuvant chemotherapy prior to resection. Further studies are required to determine how different IDRFs influence surgical risk.

Background

General surgery residents frequently access YouTube® for educational walkthroughs of surgical procedures. The aim of this study is to evaluate the educational quality of YouTube® video walkthroughs on Laparoscopic Roux-en-Y gastric bypass (LRYGB) using a validated video assessment tool.

Methods

A retrospective review of YouTube® videos was conducted for “laparoscopic Roux-en-Y gastric bypass”, “laparoscopic RYGB”, and “laparoscopic gastric bypass.” The top 100 videos from three YouTube® searches were gathered and duplicates were removed. Included videos were categorized as Physician (produced by individual physician), Academic (university/medical school), or Society (professional surgical society) and rated by three independent investigators using the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool (0–18). The data were analyzed using one-way ANOVA with Bonferroni correction and Spearman's correlation test.

Results

Of 300 videos gathered, 31 unique videos met selection criteria and were analyzed. The average LAP-VEGaS score was 8.67 (SD 3.51). Society videos demonstrated a significantly higher mean LAP-VEGaS score than Physician videos (p = 0.023). Most videos lacked formal case presentation (71%), intraoperative findings (81%), and operative time (76%). No correlation was demonstrated between LAP-VEGaS scores and number of likes or views, video length, or upload date.

Conclusions

LRYGB training videos on YouTube® generally do not adhere to the LAP-VEGaS guidelines and are of poor educational quality, signaling areas of improvement for educators.

Background

Non-traumatic emergency abdominal surgeries are common in most healthcare settings. To a significant extent, the outcomes of treatment are determined by the promptness of surgical interventions. However, the in-hospital waiting time which reflects perioperative promptness remains largely unexplored in developing countries.

Objective

To describe the preoperative waiting time, identify the causes of delays, and determine subsequent outcomes for non-traumatic emergency abdominal surgeries.

Methods

A cross-sectional study was conducted at a consultant zonal hospital in northern Tanzania from September 2012 to March 2013. Patients admitted and surgically treated for non-traumatic acute abdominal conditions were consecutively sampled. Sociodemographic and clinical data were obtained from medical records. Delays in surgical interventions were assessed based on observations at the Emergency Department and record analysis. Descriptive statistics and regression analysis were used to summarize the data and assess for factors influencing post-operative outcomes, respectively.

Results

The study included 111 participants with a median age of 29 years (IQR=18-53). The median in-hospital preoperative waiting was 10.5 hours (IQR=6.6-14.7), with a substantial majority (78.4%) experiencing delays beyond 6 hours. The frequent reasons for delayed surgery included personnel shortage (37.8%), unavailable theater space (31.5%), and investigation-related factors (28.8%). Delayed hospital presentation (symptoms ≥24 hours) (OR=3.9, 95% CI=1.0-14.9) and prolonged waiting time (>6 hours) (OR=2.7, 95% CI=1.0-7.2) were significantly associated (P < 0.05) with in-hospital complications that included wound dehiscence (0.9%), re-operation (3.6%), surgical site infection (18.0%), and complications necessitating Intensive Care Unit admission (36.9%). The in-hospital operative mortality rate was 18.0%. Age of ≤40 years (OR=0.1, 95% CI=0.04-0.4) and ASA-PS class I-II (OR=0.1, 95% CI=0.0-0.3) were identified as significant (P < 0.001) protective factors against operative mortality.

Conclusion

These benchmark findings highlight the multifactorial nature of the reasons for delayed surgical interventions and its association with postoperative complications; offering a potential avenue to enhance surgical efficiency in the index and comparable settings.

Objectives

Abdominoperineal resection (APR) is considered the gold standard surgical treatment for ultra-low rectal cancer. Anus-preserving alternative procedures have been tested to avoid the need for a permanent colostomy. The present study compares the functional and oncological outcomes of the traditional APR methods with inter-sphincteric resection (ISR).

Methods

Sixty patients with ultra-low rectal cancers that underwent tumor resection using the ISR and APR methods were compared retrospectively. Patients' demographic information as well as tumor characteristics were evaluated. All patients were followed after the operation every three months for two years, and then every six months for at least three years.

Results

Thirty-four (56.6%) patients were male, and 26 (43.3%) were females, which showed no statistical significance between the two groups. The mean tumor distance from the anal verge in the APR group was 5.11±0.06 cm and in the ISR group was 5.22±1.1 cm. In the APR group, 9 (30%) patients developed primary tumor recurrence, while in the ISR group, 10 (33.3%) patients had relapses. The observed difference was not statistically significant. However, the study showed that patients with a T stage of T2 or higher had a higher probability of tumor recurrence.

Conclusion

There is no significant difference in the efficacy of the ISR method compared with the conventional APR for the treatment of ultra-low rectal cancer.

Background

Hiatal hernia (HH) is routinely reported in 40% of bariatric surgery patients. Left unrepaired, HH can lead to post-surgical reflux, regurgitation, and vomiting.

Objectives

We hypothesize that patients with pre-operative reflux symptoms and a higher body mass index (BMI) will receive hiatal hernia repairs (HHR) more often. The study aim was to analyze the variables that drive HHR decision by operating surgeons.

Methods

The records of 551 patients who underwent endoscopy in preparation for bariatric surgery were analyzed. Prevalence of HH was derived based on esophagogastroduodenoscopy (EGD) findings performed by a bariatric surgeon during patients’ bariatric surgery. The relationship between categorical participant attributes was calculated using a significance level of 0.05.

Results

The groups consisted of 295 Roux-en-Y gastric bypass (RYGB) and 264 sleeve gastrectomy (SG) patients with preoperative HH identified in 310 patients. SG and a decreased BMI were significant for receiving a HHR. Type II diabetes (T2D), duodenitis found on EGD and pathology report, esophagitis, and Roux-en-Y gastric bypass (RYGB) were significant for not receiving a HHR. Only duodenitis, RYGB, and SG were found to be significant factors after multivariate analysis.

Conclusions

While some pre-operative patient characteristics may not impact a surgeon's HHR decision in the bariatric population, our study suggests that duodenitis, SG, and RYGB may influence a surgeon's HHR decision.

Background

In our center, patients with pancreatic cancer traditionally had Whipple's resections by general surgery teams until January 2013 when a hepatopancreatobiliary (HPB) was introduced. We compared outcomes before and after introduction of HPB teams.

Methods

Data were collected from the records of all patients booked for Whipple's resections over a 12-year period. The data were divided into two groups: Group A consisted of the 6-year period from January 1, 2007 to December 30, 2012 during which all resections were performed by GS teams. Group B comprised patients in the 6-year period from January 1, 2013 to December 30, 2019 during which operations were performed by HPB teams. All statistical analyses were carried out using SPSS ver 16.0 and a P Value <0.05 was considered statistically significant.

Results

The patients selected for Whipple's resections in Group A had statistically better performance status and lower anaesthetic risk. Despite this, patients in Group A had higher conversions to palliative operations (66% vs 5.3%), longer mean operating time (517±25 vs 367±54 min; P<0.0001), higher blood loss (3687±661 vs 1394±656 ml; P<0.0001), greater transfusion requirements (4.3±1.3 vs 1.9±1.4 units; P<0.001), greater likelihood of prolonged ICU stay (100% vs 40%; P=0.19), higher overall morbidity (75% vs 22.2%; P=0.02), higher major morbidity (75% vs 13.9%; P=0.013), more procedure-related complications (75% vs 9.7%; P=0.003) and higher mortality rates (75% vs 5.6%; P<0.0001). The HPB teams were more likely to perform vein resection and reconstruction to achieve clear margins (26.4% vs 0; P=0.57).

Conclusion

This paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple's procedures.

Background

Tonsillitis places a significant strain on healthcare services, with rising admission rates over recent years. There is an urgent need for strategies to alleviate unprecedented demand on secondary care via safe alternatives to hospital admission. This quality improvement project demonstrates development of an early discharge pathway in combination with an ENT-led Surgical Same Day Emergency Care (SDEC) unit.

Methods

All cases of acute tonsillitis (n = 127) and peritonsillar abscess (n = 43) were reviewed across two intervention phases (Aug-Oct 2021 and June-Oct 2022), which each involved a retrospective baseline audit, followed by post-intervention prospective audit cycles to assess hospital length of stay (LOS) and readmission rates.

Results

Introduction of a tonsillitis management protocol resulted in a reduction in mean LOS from 22 to 12 h (p = 0.004). Mean LOS reverted to 20 h in the second baseline audit. Further audit cycles demonstrated a sustained reduction in mean LOS to 13 h (p = 0.017) with use of the SDEC. Readmission rates remained low through all audit cycles.

Conclusion

Patients with acute tonsillitis can be safely managed via an early discharge pathway. Use of SDEC to deliver this protocol reduces pressure on front-door services, reduces LOS and does not affect readmission rate.

ChatGPT is a chatbot built on a natural language processing model which can generate human-like responses to prompts given to it. Despite its lack of domain-specific training, ChatGPT has developed remarkable accuracy in interpreting clinical information. In this article, we aim to assess what role ChatGPT can serve in medical writing. We recruited a first-year medical student with no prior experience in writing case reports to write a case report on a complex surgery with the assistance of ChatGPT. After a thorough evaluation of its responses, we believe that ChatGPT is a powerful medical writing tool that can be used to generate summaries, proofread, and provide valuable medical insight. However, ChatGPT is not a substitute for a study author due to several significant limitations, and should instead be used in conjunction with the author during the writing process. As the impact of natural language processing models such as ChatGPT grows, we suggest that guidelines be established on how to better utilize this technology to improve clinical research rather than outright prohibiting its usage.

Introduction

Ischemic colitis is a common manifestation of intestinal ischemia and is potentially a surgical emergency. Although such surgical emergencies were historically approached via open exploration, it is uncertain if there is a role for minimally invasive techniques. This study compares open vs laparoscopic colectomy techniques in the management of ischemic colitis.

Methods

Using the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) database, patients with ischemic colitis undergoing colectomy from 2005 to 2019 were compared. The primary outcome of interest was 30-day mortality. Additional outcomes of interest were procedure related readmission, procedure related reoperation, length of stay, surgical site infections (SSI), septic shock, and other complications. Outcomes of interest were compared using multivariate logistic regression.

Results

7,928 patients had ischemic colitis with 7,209 undergoing open colectomy and 719 undergoing laparoscopic colectomy. The mortality rate was significantly lower using a laparoscopic approach compared to open (6.4% vs 26%, p=<0.001) and associated with a lower odd of mortality (OR 0.58; 95% CI [0.35, 0.95]). Procedure related reoperation was lower in the laparoscopic group (6.5% vs 11%, p<0.001), but multivariate analysis was not significant (OR 0.65; 95% CI [0.43,1]). Readmission rates were not statistically different (12% vs 10%, p = 0.2). Postoperative length of stay (7 vs 12 days, p=<0.001), septic shock (6.7% vs 27%, p=<0.001), and organ space SSI (3.2% vs 6.9%, p=<0.001) were significantly decreased using a laparoscopic approach.

Discussion

30-day postoperative mortality was significantly lower using a laparoscopic. Patients that had a laparoscopic colectomy had shorter hospital stays. While patients that underwent laparoscopic procedures tended to be less sick, multivariate analysis showed decreased rates of sepsis and surgical site infections compared to open colectomies when correcting for these factors.

Conclusion

Laparoscopic colectomy may be a better surgical approach for patients with ischemic colitis compared to open colectomy.