Different Surgeon, Different Duration: Lack of Consensus on the Appropriate Duration of Antimicrobial Prophylaxis and Therapy in Surgical Practice.

Background: The principles of antimicrobial stewardship promote the appropriate prescribing of agents with respect to efficacy, safety, duration, and cost. Antibiotic resistance often results from inappropriate use (e.g., indication, selection, duration). We evaluated practice variability in duration of antimicrobials in surgical infection treatment (Rx) or prophylaxis (Px). Hypothesis: There is lack of consensus regarding the duration of antibiotic Px and Rx for many common indications. Methods: A survey was distributed to the Surgical Infection Society (SIS) regarding the use of antimicrobial agents for a variety of scenarios. Standard descriptive statistics were used to compare survey responses. Heterogeneity among question responses were compared using the Shannon Index, expressed as natural units (nats). Results: Sixty-three SIS members responded, most of whom (67%) have held a leadership position within the SIS or contributed as an annual meeting moderator or discussant; 76% have been in practice for more than five years. Regarding peri-operative Px, more than 80% agreed that a single dose is adequate for most indications, with the exceptions of gangrenous cholecystitis (40% single dose, 38% pre-operative +24 hours) and inguinal hernia repair requiring a bowel resection (70% single dose). There was more variability regarding the use of antibiotic Px for various bedside procedures with respondents split between none needed (range, 27%-66%) versus a single dose (range, 31%-67%). Opinions regarding the duration of antimicrobial Rx for hospitalized patients who have undergone a source control operation or procedure varied widely based on indication. Only two of 20 indications achieved more than 60% consensus despite available class 1 evidence: seven days for ventilator-associated pneumonia (77%), and four plus one days for perforated appendicitis (62%). Conclusions: Except for peri-operative antibiotic Px, there is little consensus regarding antibiotic duration among surgical infection experts, despite class 1 evidence and several available guidelines. This highlights the need for further high-level research and better dissemination of guidelines.

Perceptions on gender disparity in surgery and surgical leadership: A multicenter mixed methods study.

BACKGROUND: Our objective was to identify perceptions of the environment for women in surgery among 4 academic institutions. METHODS: Faculty surgeons and senior surgery residents were randomly selected to participate in a parallel study with concurrent quantitative and qualitative data collection. Outcomes were perceptions of the environment for women in surgery. Measures included semi-structured interviews, survey responses, and responses to scenarios. RESULTS: Saturation was achieved after 36 individuals were interviewed: 14 female (8 faculty, 6 residents) and 22 male (18 faculty, 4 residents) surgeons. Men (100%) and women (86%) reported gender disparity in surgery and identified 6 major categories which influence disparity: definitions of gender disparity, gaps in mentoring, family responsibility, disparity in leave, unequal pay, and professional advancement. Overall 94% of participants expressed concerns with gaps in mentoring, but 64% of women versus 14% of men reported difficulties finding role models who faced similar obstacles. Over half (53%) reported time with loved ones as their biggest sacrifice to advance professionally. Both female and male respondents expressed system-based biases favoring individuals willing to sacrifice family. A global subconscious bias against the expectations, abilities, and goals of female surgeons were perceived to impede promotion and advancement. CONCLUSION: Both female and male surgeons report substantial gender-based barriers in surgery for women. Despite improvements, fundamental issues such as lack of senior role models, limited support for surgeons with families, and disparities in hiring and promotion persist. This is an opportunity to make substantive changes to the system and eliminate barriers for women joining surgery, advancing their careers, and achieving their goals in a timely fashion.

Extracorporeal shock wave lithotripsy of pancreatic duct stones using the Healthtronics LithoTron lithotriptor and the Dornier HM3 lithotripsy machine.

PURPOSE: Pancreatic duct stones, which are most often a result of alcohol induced chronic pancreatitis, can lead to chronic abdominal pain, pseudocysts, and exocrine and endocrine failure of the pancreas. Others have reported success using extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for pancreatic stones. We report our experience with pancreatic ESWL using the LithoTron (Healthtronics, Marietta, Georgia) and HM3 (Dornier) lithotripsy machines. MATERIALS AND METHODS: We performed pancreatic ESWL in 23 patients in 4 years, including in 12 with the LithoTron and in 11 with the HM3. After ESWL endoscopic retrograde cholangio-pancreatography (ERCP) was performed in all cases. Stone-free status was defined as no stone fragments visualized or the elimination of all post-ESWL stones by ERCP. RESULTS: Stone-free status was documented in 83% and 82% of patients treated with the LithoTron and HM3, respectively, and 2 per group later required open surgical intervention. There were no changes in pancreatic enzymes and no cases of sepsis or fever after ERCP. CONCLUSIONS: In association with post-procedure ERCP pancreatic ESWL is an effective and safe procedure that enables patients with obstructing pancreatic duct stones recalcitrant to primary endoscopic extraction to avoid a potentially morbid open procedure. The HM3 and LithoTron have comparable efficacy and safety. This modality is particularly effective for a stone aggregate of less than 20 mm., while a larger stone burden of greater than 20 mm. in aggregate and multiple stones are clear risk factors for treatment failure.