Emergency general surgery in a public hospital in Malaysia.

INTRODUCTION: Patients undergoing emergency general surgery (EGS) are at risk for death and complications. Information on the burden of EGS is critical for developing strategies to improve the outcomes. METHODS: In this retrospective cohort study, medical records of all general surgical operations in a public hospital were reviewed for the period 1st January 2017 to 31st December 2017. Data on patient demographics, operative workload, case mix, time of surgery and outcomes were analysed. RESULTS: Of the 2960 general surgical operations that were performed in 2017, 1720 (58.1%) of the procedures were performed as emergencies. The mean age for the patients undergoing emergency general surgical procedures was 37.9 years (Standard Deviation, ±21.0), with male preponderance (57.5%). Appendicitis was the most frequent diagnosis for the emergency procedures (43%) followed by infections of the skin and soft tissues (31.6%). Disorders of the colon and rectum ranked as the third most common condition, accounting for 6.7% of the emergency procedures. Majority of emergency surgery (59.3%) took place after office hours and on weekends. Post-operative deaths and admissions to critical care facilities increased during EGS when compared to elective surgery, p<0.01. CONCLUSIONS: EGS constitutes a major part of the workload of general surgeons and it is associated significant risk for death and post-operative complications. The burden of EGS must be recognised and patient care systems must evolve to make surgery safe and efficient.

Case distributions in general surgery residency: Subspecialization occurs before fellowship.

BACKGROUND: In the era of subspecialization and duty-hour restrictions, many General Surgery residents desire additional training in their future subspecialty areas. This study examines the relationship between case distributions performed by General Surgery residents and their chosen future subspecialty. METHODS: A retrospective review of Accreditation Council for Graduate Medical Education case logs of 101 graduated General Surgery residents at a single academic institution (2002-2018) was performed. The total number of operative cases performed during General Surgery residency overall and in Accreditation Council for Graduate Medical Education-defined categories were compared between residents with differing areas of future subspecialization. RESULTS: Residents pursuing surgical fellowships in Endocrine, Cardiothoracic, Vascular, and Trauma/Critical Care Surgery logged respectively more endocrine (63 [11] vs 32 [13]; P < .001), thoracic (61 [15] vs 41 [13]; P < .001), vascular (225 [38] vs 162 [38]; P < .001), and operative trauma (83 [29] vs 71 [25]; P = .045) cases, compared with program average. Residents pursuing General Surgery (no fellowship) performed significantly more endoscopies (131 [47] vs 105 [28]; P = .029) than peers. Residents pursuing Breast, Oncology, Colorectal, and Pediatric Surgery fellowships performed numerically (non-significantly) more breast (94 [16] vs 78 [20]; P = .180), liver/pancreas (39 [3.1] vs 33 [8.0]; P = .173), large intestinal (132 [30] vs 125 [24]; P = .507), and pediatric (173 [27] vs 155 [37]; P = .832) cases, respectively, compared with peers. The majority of these additional cases were performed in postgraduate years 3 to 5. CONCLUSION: In this single-institution study, many General Surgery residents perform more cases than peers in respective areas of future subspecialization. This may reflect residents at the reporting institution, and similar large, university-based programs seeking focused training in preparation for fellowship while still meeting case-volume minimums in all Accreditation Council for Graduate Medical Education-defined categories.

Military Medicine and the Academic Surgery Gender Gap.

INTRODUCTION: Gender disparity in academic medicine has been well described in the civilian sector. This has not yet been evaluated in the military health system where hundreds of female surgeons are practicing. Military service limits factors such as part time work and control over time spent away from family, which are often cited as contributors to the pay and promotion gap in civilian academic medicine. The military has explicit policies to limit discrimination based on gender. Pay between men and women is equal as it is based on rank and time in rank. One would expect to see less disparity in promotion through the academic ranks for military female surgeons given this otherwise equal treatment. This has not previously been objectively tracked or reported. It is beneficial to characterize the military academic medicine gender gap and benchmark against national data to define the academic gender gap and lay the groundwork for future work to identify factors contributing to the observed difference. MATERIAL AND METHODS: This study was granted exemption from the Walter Reed National Military Medical Center (WRNMMC) Internal Review Board (IRB). The Uniformed Services University (USU) Department of Surgery academic appointment list was reviewed to assess female representation in the categories of Instructor, Assistant Professor, Associate Professor, Professor, and Other. Defense Manpower Data Center (DMDC) and the US Navy Bureau of Medicine and Surgery (BUMED) were assessed for total numbers of female surgeons on active duty, and numbers were compared with nationally published Association of American Medical Colleges (AAMC) data using a logistic regression model. RESULTS: There was a higher proportion of women in academic positions in the civilian cohort than in the military cohort (OR: 1.84; CI: 1.53-2.21, p < .0001). This difference was observed at every level of academic achievement. A higher percentage of women were observed at lower levels of professorship than at higher levels; instructors were more likely to be women than assistant professor (OR: 1.44, CI:1.16-1.79), associate professor (OR: 2.24, CI: 1.77-2.84), or full professor (OR:4.61, CI: 3.57-5.94). CONCLUSIONS: Fewer female surgeons in military medicine hold academic appointment when compared with their counterparts in civilian medicine. Similar to the civilian sector, military academic surgery also demonstrates less likelihood of female representation in higher academic stations. This discrepancy in representation follows a linear trend over the different ranks. This discrepancy has not been previously documented. The military offers a unique opportunity to study the issue of gender imbalance in academic promotion practices given its otherwise equal treatment of males and females. Additional studies will be necessary to understand uniformed female surgeons' barriers to academic advancement.

[Enrico Bottini (1835-1903), Italian Physician and Politician: A Master of Antisepsis and a Pioneer of Modern Surgery] / Enrico Bottini (1835­1903), medico e politico Italiano: Maestro dell'anti-sepsi e pioniere della chirurgia moderna

Enrico Bottini (Stradella, Pavia, 7 September 1835 - Porto Maurizio, Sanremo, 11 March 1903) was a multifaceted surgeon, who left a strong mark in modern surgery, not only Italian but worldwide. A pupil of Porta and Ribeti, as well as the distinguished French surgeon and anatomist Charles-Marie-Édouard Chassaignac, he has dedicated himself throughout his career to various areas of medicine, ranging from bacteriology and anti-sepsis (use of a derivative of phenic acid) to urological surgery (the so-called "endo-urethral galva-cauterization", also called Bottini's operation, or Perineal incision according to Bottini). He has also successfully dedicated himself to gynecology (trans-vaginal hysterectomy for uterine cancer and surgical treatment of vesicovaginal fistulas), maxillofacial surgery (endo-oral resection of the maxilla, subperiosteal resection of the mandible for the treatment of the stable jaw, total amputation of the larynx and the tongue for carcinomas), the dermosurgery (use of the electrocautery), and the vascular surgery (resection of the inferior vena cava). He was also an important Italian politician, first as a deputy and then as a senator.

Medical Devices; General and Plastic Surgery Devices; Classification of the Wound Autofluorescence Imaging Device. Final order.

The Food and Drug Administration (FDA or we) is classifying the wound autofluorescence imaging device into class I. We are taking this action because we have determined that classifying the device into class I will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

Video Caso Clínico: Disección Aórtica Rota Tipo Stanford A. Resolución Quirúrgica: Cirugía de Bentall De Bono / Video Case Report: Rupture Aortic Dissection Stanford Type A. Surgical Resolution: Surgery Bentall and De Bono

La disección aórtica rota que compromete la raíz y la aorta ascendente es una emergencia que requiere cirugía inmediata, debido al mal pronóstico y sus complicaciones agudas: ruptura, insuficiencia aórtica aguda, hematoma intramural y endocarditis aguda; con elevadas tasas de morbilidad y mortalidad posoperatoria temprana, estimada en las 24 horas el 1 % por cada hora, a las 48 horas 29 %, en la primera semana 44 % y a las 2 semanas 50 %; con una mortalidad global de 15 % a 35 % y una sobrevida del 65 % al 75 % en un rango de 5 años [1 - 3]. En Ecuador se llevó a cabo un estudio tipo prospectivo que incluyo 120 pacientes, llevado a cabo desde 1999 a 2000, en Guayaquil; en el que reportaron 34 casos, con edad promedio de 64 años, sexo masculino, cuyo factor de riesgo más importante fue hipertensión arterial. Se presentó en el 100 % de los casos, dolor torácico transfictivo, soplo aórtico diastólico en el 70 % y solo el 2 % presentaron infarto de miocardio posteroinferior transmural sin fibrinólisis, por ser contraindicado en pacientes con disección aórtica [4]. El tratamiento quirúrgico consiste en la resección y reemplazo de la porción rota por una prótesis vascular asociada o no al reemplazo valvular aórtico dependiendo del grado de insuficiencia. El tratamiento estará orientado en función del grado de afectación de la disección y la rotura, pudiendo requerir un reemplazo convencional de la aorta ascendente (RCAA) con o sin reemplazo total del arco aórtico (RTAA); el tratamiento de elección de la disección rota tipo A es el reemplazo de la raíz y la aorta ascendente con injerto tubular valvulado, denominado procedimiento de Bentall De Bono [1 - 3, 5, 6]. Dentro de las complicaciones postquirúrgicas se encuentran: pseudoaneurisma, disección radical recurrente o residual, cambios importantes en el diámetro de la raíz o insuficiencia aórtica significativa [7]

The rupture aortic dissection that compromises the root and the ascending aorta is an emergency that requires immediate surgery; for it is poor prognosis, acute complications: rupture, acute aortic insufficiency, intramural hematoma and acute endocarditis, with high morbidity rates and early postoperative mortality, estimated at first 24 hours in 1 % per each hour, 48 hours 29 %, in the first week 44 % and at 2 weeks 50 %; with a global mortality of 15 % to 35 % and a survival of 65 % to 75 % in a range of 5 years [1-3]. In Ecuador, a prospective study realized that included 120 patients, since 1999 to 2000, in Guayaquil; in that they reported 34 cases with an average age of 64 years, male, whose most important risk factor was hypertension. The patients presented, 100 % transfictive chest pain, diastolic aortic murmur in 70 %, and only 2 % had transmural posteroinferior myocardial infarction without fibrinolysis, as it was contraindicated in patients with aortic dissection [4]. Surgical treatment consists of the resection and replacement of the broken portion by a vascular prosthesis associated or not with aortic valve replacement depending on the degree of insufficiency. The treatment will be oriented according to the degree of involvement of the dissection and rupture, and may require a conventional replacement of the ascending aorta (CRAA) with or without total aortic arch replacement (TRAA); the treatment of choice for the rupture aortic dissection type A is the replacement of the root and the ascending aorta with valvular tubular graft, called the Bentall De Bono surgery [1 - 3, 5, 6]. Of the postsurgical complications we found: pseudoaneurysm, radical or recurrent radical dissection, important changes in the diameter of the root or significant aortic insufficiency

Medical Devices; General and Plastic Surgery Devices; Classification of the Magnetic Surgical Instrument System. Final order.

The Food and Drug Administration (FDA) is classifying the Magnetic Surgical Instrument System into class II (special controls). The special controls that will apply to the device are identified in this order and will be part of the codified language for the magnetic surgical instrument system's classification. The Agency is classifying the device into class II (special controls) in order to provide a reasonable assurance of safety and effectiveness of the device.

Participation of surgical residents in operations: challenging a common classification.

BACKGROUND: One important form of surgical training for residents is their participation in actual operations, for instance as an assistant or supervised surgeon. The aim of this study was to explore what participation in operations entails and how it might be described and analyzed. METHODS: A qualitative study was undertaken in a major teaching hospital in London. A total of 122 general surgical operations were observed. A subsample of 14 laparoscopic cholecystectomies involving one or more residents was analyzed in detail. Audio and video recordings of eight operations were transcribed and analyzed linguistically. RESULTS: The degree of participation of trainees frequently shifted as the operation progressed to the next stage. Participation also varied within each stage. When trainees operated under supervision, the supervisors constantly adjusted their degree of control over the resident's operative maneuvers. CONCLUSIONS: Classifications such as "assistant" and "supervised surgeon" describing a trainee's overall participation in an operation potentially misrepresent the varying involvement of resident and supervisor. Video recordings provide a useful alternative for documenting and analyzing actual participation in operations.

Comparing existing national and international classification systems of surgical procedures with the CEN/ISO 1828 ontology framework standard.

Among different standardization strategies for biomedical terminologies the European Standard Body CEN TC 251 followed by ISO TC 215 have stated that it was not possible to convince the different European or international member states using different national languages to agree on a reference clinical terminology or to standardize a detailed language independent biomedical ontology. Since 1990 they have developed since an approach named the Categorial Structure that standardises only the terminologies' model structure. The methodology for the Categorial Structure development and a comparison of the different existing classification systems based on this ontology framework is presented as a step towards increased interoperability between biomedical terminologies through conformity to a minimum set of ontological requirements.

Surgeon distress as calibrated by hours worked and nights on call.

BACKGROUND: The relationships of working hours and nights on call per week with various parameters of distress among practicing surgeons have not been previously examined in detail. STUDY DESIGN: More than 7,900 members of the American College of Surgeons responded to an anonymous, cross-sectional survey. The survey included self-assessment of their practice setting, a validated depression screening tool, and standardized assessments of burnout and quality of life. RESULTS: There was a clear gradient between hours and burnout, with the prevalence of burnout ranging from 30% for surgeons working <60 hours/week, 44% for 60 to 80 hours/week, and 50% for those working >80 hours/week (p < 0.001). When correlated with number of nights on call, burnout exhibited a threshold effect at ≥2 nights on call/week (≤1 nights on call/week, 30%; ≥2 nights on call/week, 44% to 46%; p < 0.0001). Screening positive for depression rate also correlated strongly with hours and nights on call (both p < 0.0001). Those who worked >80 hours/week reported a higher rate of medical errors compared with those who worked <60 hours/week (10.7% versus 6.9%; p < 0.001), and were twice as likely to attribute the error to burnout (20.1% versus 8.9%; p = 0.001). Not surprisingly, work and home conflicts were higher among surgeons who worked longer hours or had ≥2 nights on call. A significantly higher proportion of surgeons who worked >80 hours/week or had >2 nights on call/week would not become a surgeon again (p < 0.0001). CONCLUSIONS: Number of hours worked and nights on call per week appear to have a substantial impact on surgeons, both professionally and personally. These factors are strongly related to burnout, depression, career satisfaction, and work and home conflicts.

Cited Brazilian papers in general surgery between 1970 and 2009.

OBJECTIVES: To identify the most cited articles in general surgery published by Brazilian authors. INTRODUCTION: There are several ways for the international community to recognize the quality of a scientific article. Although controversial, the most widely used and reliable methodology to identify the importance of an article is citation analysis. METHODS: A search using the Institute for Scientific Information citation database (Science Citation Index Expanded) was performed to identify highly cited Brazilian papers published in twenty-six highly cited general surgery journals, selected based on their elevated impact factors, from 1970 to 2009. Further analysis was done on the 65 most-cited papers. RESULTS: We identified 1,713 Brazilian articles, from which nine papers emerged as classics (more than 100 citations received). For the Brazilian contributions, a total increase of about 21-fold was evident between 1970 and 2009. Although several topics were covered, articles covering trauma, oncology and organ transplantation were the most cited. The majority of classic studies were done with international cooperation. CONCLUSIONS: This study identified the most influential Brazilian articles published in internationally renowned general surgery journals.

General surgical operative duration is associated with increased risk-adjusted infectious complication rates and length of hospital stay.

BACKGROUND: Studies of specific procedures have shown increases in infectious complications with operative duration. We hypothesized that operative duration is independently associated with increased risk-adjusted infectious complication (IC) rates in a broad range of general surgical procedures. STUDY DESIGN: We queried the American College of Surgeons National Surgical Quality Improvement Program database for general surgical operations performed from 2005 to 2007. ICs (wound infection, sepsis, urinary tract infection, and/or pneumonia) and length of hospital stay (LOS) were evaluated versus operative duration (OD, ie, incision to closure). Multivariable regression adjusted for 38 patient risk variables, operation type and complexity, wound class and intraoperative transfusion. We also analyzed isolated laparoscopic cholecystectomies in patients of American Society of Anesthesiologists class 1 or 2, without intraoperative transfusion and with a clean or clean-contaminated wound class. RESULTS: In 299,359 operations performed at 173 hospitals, unadjusted IC rates increased linearly with OD at a rate of close to 2.5% per half hour (chi-square test for linear trend, p < 0.001). After adjustment, IC risk increased for each half hour of OD relative to cases lasting

Cited Brazilian papers in general surgery between 1970 and 2009

OBJECTIVES: To identify the most cited articles in general surgery published by Brazilian authors. INTRODUCTION: There are several ways for the international community to recognize the quality of a scientific article. Although controversial, the most widely used and reliable methodology to identify the importance of an article is citation analysis. METHODS: A search using the Institute for Scientific Information citation database (Science Citation Index Expanded) was performed to identify highly cited Brazilian papers published in twenty-six highly cited general surgery journals, selected based on their elevated impact factors, from 1970 to 2009. Further analysis was done on the 65 most-cited papers. RESULTS: We identified 1,713 Brazilian articles, from which nine papers emerged as classics (more than 100 citations received). For the Brazilian contributions, a total increase of about 21-fold was evident between 1970 and 2009. Although several topics were covered, articles covering trauma, oncology and organ transplantation were the most cited. The majority of classic studies were done with international cooperation. CONCLUSIONS: This study identified the most influential Brazilian articles published in internationally renowned general surgery journals.

Maryland's surgical workforce-2007: an in-depth analysis and implications for the future.

BACKGROUND: Critical decisions about the future supply of surgeons must be based on an accurate assessment of current surgical manpower. This study examined the demographics and clinical activities of seven surgical subspecialty groups on the frontlines of health care in Maryland. These data are compared with those customarily quoted in the literature, and the implications of these findings are discussed. STUDY DESIGN: Clinical activity of surgeons versus administrative, teaching, research, and other obligations was determined after interviews with medical directors in all of Maryland's 52 acute care hospitals. Additional information was obtained from residency program directors, chairmen, and others, if necessary. Data were stratified by specialty, location of practice, and age of surgeon. RESULTS: Data were analyzed for general, orthopaedic, ENT, vascular, and noncardiac thoracic surgeons, neurosurgeons, and urologists. Surgeons in rural western, eastern, and southern regions spent 86.3% of their time in care of patients compared with 70.3% for surgeons in urban, suburban, or teaching settings. Across the state, the number of surgeons providing care to patients per 100,000 residents was below reported requirements in general surgery, vascular, and noncardiac surgery. Overall, 40.3% of surgeons were 55 years or older in 2007. CONCLUSIONS: Critical shortages of qualified surgeons currently exist in many regions of Maryland, especially in rural regions. Administrative, teaching, and research activities significantly reduce the amount of time surgeons are able to devote to patient care, particularly in academic and suburban settings. Fewer surgeons are available to care for patients in Maryland, and they are significantly older than assumed in manpower databases. Access to surgical care in Maryland will be jeopardized if these issues are not considered in future health care workforce discussions.

Avaliação de hipotermia na sala de recuperação pós-anestésica em pacientes submetidos a cirurgias abdominais com duração maior de duas horas / Hypothermia evaluation in post-anesthetic recovery room after abdominal surgeries longer than 2 hours

Introdução: Hipotermia não intencional é caracterizada por temperatura sanguínea central inferior a 36°C e pode estar presente em 53-85% dos adultos que chegam à Sala de Recuperação Pós-anestésica (SRPA). Objetivos: Avaliar a hipotermia na SRPA em pacientessubmetidos a cirurgias abdominais com duração maior de duas horas, no Hospital Nossa Senhora da Conceição, em Tubarão – SC. Métodos: Foi realizado um estudo transversal no qualpacientes submetidos a cirurgias abdominais com duração maior de duas horas, tiveram as temperaturas axilaresmonitoradas antes e depois da cirurgia e no momento da alta da SRPA. As variáveis utilizadas foram gênero,faixa etária, etnia, peso, altura, tipo de cirurgia, especialidade, tempo de cirurgia e tempo de permanência naSRPA. Resultados: A média de temperatura após a cirurgia foi de 34,5°C, já a média da alta da SRPA foi de35,7°C. Pacientes acima de 40 anos apresentaram uma média de 1,0°C menor em relação ao grupo com idadeinferior ao final da cirurgia. O grupo de pacientes com menos de 70 Kg obteve uma temperatura média menor após a cirurgia quando comparado ao outro grupo. Cirurgias com mais de 180 minutos e tempo na SRPA superiora 180 minutos apresentaram menor temperatura média posterior. Conclusões: A média de temperatura após a cirurgia foi classificada em hipotermia de grau leve. Característicasdo paciente como peso menor que 70Kg, idade maior de 40 anos e cirurgias prolongadas estiveram associadas a uma menor temperatura pós-operatória.

Introduction: Non intentional hypothermia is characterized by central blood temperature lower than 36ºC,and is present in 53-85% of adults upon arrival at the post-anesthetic recovery room. Objective: To analyze hypothermia in the post-anestheticroom, in patients submitted to abdominal surgery with duration of over two hours, in the Nossa Senhora da Conceição Hospital, in Tubarão – SC. Methods: A cross sectional study was realized.Patients submitted to abdominal surgeries with over two hours of duration, had their axillaries temperatures monitored, before and after of the surgery, and at the timeof discharge of the post-anesthetic recovery room. The variables used were, gender, age group, ethnicity, weight, height, type of surgery, and time spent in the post- anesthetic recovery room. Results: The average body temperature after surgery was 34.5°C while the average body temperature atthe post-anesthetic recovery room was 35.7°C. Patients over 40 years old presented an average temperature0.5°C lower when compared to the group less than this age, at the end of the surgery. The group of patientsweighting less than 70 Kg obtained a lower average temperatureafter surgery when compared to the other group. Surgeries longer than 180 minutes and patients that remainedmore than 180 minutes in the post-anesthetic recovery room presented lower average temperatures. Conclusion: The average temperature after surgery was classified as low level hypothermia. Patients characteristicssuch as weight lower than 70 Kg, age over 40 years old and prolonged surgeries were associated with lower post-operative temperature.