Effects of In-House Calls on Medical Students' Perspectives of Surgical Education and Future Career Opportunities.

Background: It has been shown that surgical residents who took few or no in-house calls during medical school felt less prepared for the residency. In this study, our objective was to assess the impact of in-house calls carried out by medical students on their perceptions of medical training, including the influence on specialty choice. Methods: The students were asked to complete an anonymized questionnaire at the first and last day of their general surgery clerkship. Students were asked regarding importance for medical training and education, preparation for the internship, learning opportunities, skills acquisition; negative effects, including fatigue, negative effect over medical training, personal life, and physical and mental health derangements; and the student's perception of the residents' in-house calls and parameters affecting specialty selection: difficulty of the residency, prestige, and future career opportunities. Results: A total of 42 medical students responded to 84 questionnaires. There was a significant difference in the importance of calls among male students before the beginning of the clerkships compared with the end of the clerkship (4.53 versus 4.21, P = .034). At the end of general surgery clerkship, students indicated that the calls less impaired studying during the clerkship (2.5 versus 2.21, P < .05) compared with the beginning of the clerkship. Female students ranked the calls as less demanding at the end of the clerkship (2.53 versus 2.12, P < .05). The impact of the residency difficulty on the selection of their future specialty was rated higher by the students at the end of the clerkship compared with their expectations at the beginning (3.13 versus 2.85, P = .033). Conclusions: In conclusion, our study demonstrates that in-house calls performed by medical students during their general surgery clerkships have a significant influence on their perceptions of medical training and choice of specialty. The study also highlights the importance of gender differences in the students' perception of the importance and impact of calls on their well-being.

Empyema Secondary to Pneumonia: Whom Should We Operate?

Introduction: Empyema secondary to pneumonia is a common condition. A significant number of patients will require surgical intervention for drainage and decortication. The aim of this study was to identify predictive factors for surgical intervention. Materials and Methods: The medical records of patients who were diagnosed with empyema secondary to pneumonia between the years 2010 and 2019 in a university hospital were included in the study. Patients who underwent surgical intervention were defined as group A and nonoperative treatment as group B. Clinical and laboratory data were collected from medical records and patients' chest computerized tomography (CT) scans were reviewed. Results: A total of 194 patients were included in the study-86 patients were included in group A and 108 patients in group B. Several parameters on admission were found to have a statistically significant correlation with surgical intervention: younger age, higher systolic blood pressure, and elevated white blood count. Multivariant analysis showed that younger age was found to have a statistically significant correlation with operative intervention (adjusted odds ratio = 0.971, P = .023). A statistically significant correlation between surgical intervention and survival (adjusted hazard ratio [HR] = 1.762, P = .046) and an inverse correlation between age and survival (adjusted HR = 0.050, P < .001) were found. Surgical intervention was associated with increased survival irrespective of age. A total of 42 CT scans were available for review. The mean density of the empyema fluid in group A was higher by 4.3 hounsfield units compared to group B (P < .067). Conclusions: Younger age was found to be associated with surgical intervention among patients suffering from empyema secondary to pneumonia. Surgical intervention was associated with increased long-term survival, irrespective of patients' age. Several radiologic characteristics were associated with the need for surgery in this study: empyema fluid density, pleural thickening, and fluid loculations. Additional prospective studies are required to ascertain these results.

Hiatal Hernia Repair: Can We Predict the Need for Mesh?

Introduction: The use of mesh for paraesophageal hernia repair is controversial due to concerns about long-term complications. This study aimed to investigate whether preoperative imaging characteristics of diaphragmatic hernia could predict the need for mesh repair. Methods: The records of all patients who underwent laparoscopic diaphragmatic hernia repair between September 2015 and September 2022 were reviewed. Patients' preoperative computerized tomography (CT) imaging was reviewed and was correlated with mesh repair. Results: A total of 53 patients were included in the study. Volumetric measurements were obtained from preoperative CT scans to assess hiatal defect area (HDA) and hernia sac volume (HSV). Mesh repair was required in 43.4% of cases, all among types II-IV. The mesh repair group had a higher mean hiatal neck height (50.8 ± 16.35 versus 43.22 ± 17.08 mm, P < .032) and higher HSV (708.53 ± 577.6 versus 346.866 ± 321.65 cm3, P < .003). There was also a borderline difference in HDA mean values (23.78 ± 17.22 versus 16.8 ± 10.41 cm2, P < .059). Conclusions: Preoperative HSV on CT scans can be a valuable predictor for the need for mesh repair during hiatal hernia surgery, aiding surgical planning and decision-making. Further research is needed to validate these findings and optimize hernia repair outcomes.

Persistent post-bariatric-surgery hypoglycemia: A long-term follow-up reassessment.

BACKGROUND AND AIM: Post-bariatric-surgery hypoglycemia (PBH) is a serious complication of bariatric surgery (BS). In our previous study about three quarters of the patients developed PBH. However long-term follow-up data is lacking to determine whether this condition improves with time. The aim of the current study was to re-assess post-BS patients who participated in our previous study and determine whether there are changes in the frequency and/or severity of hypoglycemic events. METHODS AND RESULTS: Twenty-four post-BS, post Roux-en-Y gastric-bypass (RYGB = 10), post omega-loop gastric-bypass (OLGB = 9) and post sleeve-gastrectomy (SG = 5) individuals were reevaluated in a follow-up study 34.4 ± 4 months after their previous assessment and 67 ± 17 months since surgery. The evaluation included: a dietitian assessment, a questionnaire, meal-tolerance test (MTT) and a one-week masked continuous glucose monitoring (CGM). Hypoglycemia and severe hypoglycemia were defined by glucose levels ≤54 mg/dl and ≤40 mg/dl, respectively. Thirteen patients reported questionnaire meal-related complaints, mainly non-specific. During MTT, hypoglycemia occurred in 75% of the patients, and severe hypoglycemia in a third, but none was associated with specific complaints. During CGM, 66% of patients developed hypoglycemia and 37% had severe hypoglycemia. We did not observe significant improvements in hypoglycemic events compared to the previous assessment. Despite the high frequency of hypoglycemia, it did not necessitate hospitalizations or lead to death. CONCLUSIONS: PBH did not resolve within long-term follow-up. Intriguingly, most patient were unaware of these events which can lead to underestimation by the medical staff. Further studies are needed to determine possible long term sequela of repeated hypoglycemia.

CDC25C Protein Expression Correlates with Tumor Differentiation and Clinical Outcomes in Lung Adenocarcinoma.

Given that, even after multimodal therapy, early-stage lung cancer (LC) often recurs, novel prognostic markers to help guide therapy are highly desired. The mRNA levels of cell division cycle 25C (CDC25C), a phosphatase that regulates G2/M cell cycle transition in malignant cells, correlate with poor clinical outcomes in lung adenocarcinoma (LUAD). However, whether CDC25C protein detected by immunohistochemistry can serve as a prognostic marker in LUAD is yet unknown. We stained an LC tissue array and a cohort of 61 LUAD tissue sections for CDC25C and searched for correlations between CDC25C staining score and the pathological characteristics of the tumors and the patients' clinical outcomes. Clinical data were retrieved from our prospectively maintained departmental database. We found that high expression of CDC25C was predominant among poorly differentiated LUAD (p < 0.001) and in LUAD > 1cm (p < 0.05). Further, high expression of CDC25C was associated with reduced disease-free survival (p = 0.03, median follow-up of 39 months) and with a trend for reduced overall survival (p = 0.08). Therefore, high expression of CDC25C protein in LUAD is associated with aggressive histological features and with poor outcomes. Larger studies are required to further validate CDC25C as a prognostic marker in LUAD.

Immediate Pneumothorax Diagnosis by Surgical Residents Using Portable Ultrasound.

OBJECTIVE: Feasibility of diagnosis of pneumothorax using handheld ultrasound by non-radiologists shows inconsistent results. The aim of this study is to evaluate the feasibility and accuracy of portable ultrasound for immediate diagnosis of pneumothorax by general surgery residents who underwent short training. METHODS: Patients who presented to the emergency department of a university hospital with suspected pneumothorax between 10/2018 and 12/2019 were included in the study. Patients underwent ultrasound in 2 points of each hemithorax. Sensitivity and specificity for pneumothorax diagnosis by ultrasound and physical examination were calculated and compared with chest computed tomography (CT). Patients in whom a chest tube was placed prior to ultrasound examination and those who did not undergo a CT scan were excluded from the study. RESULTS: A total of 85 patients met the inclusion criteria. Mean age was 40.7 ± 20.2 years. Pneumothorax was found among 46 patients (54%) per chest CT, and of these, 21 (46%) underwent chest tube placement following imaging. Ultrasound showed the highest sensitivity and specificity (95.6% [95% confidence interval {CI} 85.16% to 99.47%] and 97.44% [95% CI 86.40% to 99.67%], respectively). Chest x-ray had the lowest sensitivity (47.8% [95% CI 32.89% to 63.05%]) for pneumothorax detection. Physical examination showed a moderate sensitivity and specificity (82.6% [95% CI 68.58% to 92.18%] and 77.89% [95% CI 60.67% to 88.87%], respectively) for the diagnosis of pneumothorax. CONCLUSIONS: We found high accuracy rates of 2-point ultrasound in immediate pneumothorax diagnosis when performed by surgical residents who underwent a short ultrasound training. This is a fast and repeatable test, and has the potential for successful implementation in prehospital and military scenarios as well, minimizing unnecessary chest tube placements.

Negative-Pressure Vacuum Therapy for High-Output Chyle Leak Following Neck Dissection.

Chyle fistula is a challenging complication following neck dissection carrying a high morbidity and mortality rate. Herein we present a challenging case of successful management of high-output left-sided cervical chyle fistula with negative-pressure vacuum (VAC) therapy in a case where all conservative treatments failed. A 40-year-old man with lymphoma and supraglottic carcinoma underwent endoscopic resection and bilateral neck dissections. He developed high-output chyle fistula, nonresponsive to conservative treatments. Double-layered Vicryl mesh was placed between the sponge and the jugular vein to prevent vascular injury. Immediately after initiation of the VAC therapy, the output decreased, and completely stopped after 3 days. The VAC therapy was continued for additional 5 days to ensure complete seal of the fistula by granulation tissue, by which time the wound was primarily closed. VAC therapy seems to be a safe and effective treatment for high-output cervical chyle fistula following neck dissection, avoiding complex surgical interventions. Thoracic surgeons should be aware of this low-morbidity and potentially effective treatment modality for this challenging complication.

Clinical significance of rib fractures' anatomical patterns.

OBJECTIVES: Rib fractures are common and carry significant morbidity. Chest CT provides an accurate mapping of the fractures. The aim of this study is to propose an anatomical classification of rib fractures, and assess their relation to complication development. METHOD: The records of all blunt trauma patients between January 1st 2014 and December 31st 2017 at a university hospital were retrospectively reviewed. Wounded who were hospitalized with rib fractures (two and more) as the primary injury were included in the study. Based on the chest CT scans, the cohort was divided into five groups: upper ribs (1-4) fractures, anterior, lateral and posterior middle ribs (4-7) fractures, and lower ribs (9-12) fractures. Data regarding demographics, complications (pneumothorax, hemothorax, chest drains, pulmonary contusion atelectasis, pneumonia, respiratory failure and death), intensive care admission and hospital stay were collected. RESULTS: A total of 102 wounded were included in the study, with a mean age of 46.3 years. The mean number of fractured ribs per person was 3.82±1.68, and 46 wounded had displaced fractures. Rib fracture distribution was: upper ribs - 13.7%, anterior middle ribs - 28.5%, lateral middle ribs fractures - 27.5%, posterior middle ribs - 14.7%, lower ribs fractures - 15.7%. Wounded sustaining lateral middle ribs fractures had the highest complications rates in relation to any other fracture location group, with 25% respiratory failure rate. CONCLUSIONS: Lateral middle ribs fractures are associated with a higher complication rate and may require closer oabservation.

SYMPTOMATIC AND ASYMPTOMATIC HYPOGLYCEMIA POST THREE DIFFERENT BARIATRIC PROCEDURES: A COMMON AND SEVERE COMPLICATION.

Background: The prevalence of post-bariatric surgery hypoglycemia (PBH) remains unclear due to diagnostic criteria variability, types of bariatric procedures and possible unawareness. Objective: To determine the frequency, pattern and severity of symptomatic and asymptomatic hypoglycemia in subjects post three different bariatric procedures performed >1 year before evaluation and a group of obese subjects before surgery. Design and Setting: Observational cohort study. Fifty-one consecutive patients participated: post Roux-en-Y gastric-bypass (RYGB) (n=16), post omega-loop gastric-bypass (OLGB) (n=12), post sleeve-gastrectomy (SG) (n=15), obese subjects before surgery (controls) (n=8). Hypoglycemic events (glucose ≤54 mg/dL) and severe hypoglycemia (glucose ≤40 mg/dL) were evaluated by symptoms' questionnaire, mixed-meal tolerance test (MMTT) and continuous glucose monitoring (CGM). Results: According to questionnaires, meal-related complaints were reported in 11 (26%) of the surgical group and in one control subject. During MMTT, 88%, 82% and 67% experienced hypoglycemia in RYGB, OMGB and SG groups, respectively, vs. none of the controls (P<0.001). Severe hypoglycemia occurred in 38%, 45% and 7% in RYGB, OMGB and SG groups, respectively (P=0.025), but only 10 of the total operated patients (24%) reported any symptoms. During CGM, fasting hypoglycemic events occurred more in RYGB and OLGB vs. SG group: 55%, 63% and 17% respectively (P=0.036). Conclusions: PBH is very common after RYGB, OMGB and SG and can be severe especially following bypass procedures. Our results show that hypoglycemia occurs not only postprandially but also in the fasting state, especially following bypass procedures. In most cases, there were no specific complaints, possibly leading to its underestimation.

A Potentially Malignant Giant Esophageal Paraganglioma.

Paragangliomas are rare neuroendocrine tumors derived from extraadrenal autonomic paraganglia, which may secrete catecholamines. They are potentially metastatic and require very long-term follow-up. Esophageal paragangliomas are extremely rare and present a diagnostic challenge. Lack of clinical suspicion and unrecognized catecholamine hypersecretion may lead to hemodynamic instabilities during surgery. Two patients with esophageal paragangliomas were previously reported. We report a 39-year-old man with a giant high-risk esophageal paraganglioma who underwent a hybrid minimally invasive 3-hole esophagectomy.