Perceptions of medical students towards and effectiveness of online surgical curriculum: a systematic review.

BACKGROUND: Online education has been used as an adjunct modality for teaching and it attracts attention in recent years as many medical students can not accomplish their clerkship in the hospital due to COVID-19 pandemic. This study aims to collect the articles related to online surgical education for medical students, and to analyze the effectiveness of online education and the perceptions of the medical students. METHOD: We performed a systemic literature search in PubMed, MEDLINE, EMBASE, ERIC and Cochrane library. Keywords used for searching included "medical student", "online education", "online teaching", "online learning", "distance learning", "electronic learning", "virtual learning" and "surgical". Medical education research study quality instrument (MERSQI) was used for the evaluation of the quality of the searched articles. RESULTS: From 1240 studies retrieved from the databases, 13 articles were included in this study after screening. The publication year was from 2007 to 2021. The mean MERSQI score of the 13 searched articles was 12.5 +/- 1.7 (range 10.0-14.5). There were totally 2023 medical students who attended online surgical curriculum. By online course, improvement of understanding and knowledge on the studied topics could be reached. The confidence in patient encounters could be improved by online curriculum with sharing experiences, discussing, and role playing. However, students felt concentration was poor during online course. Medical students studying through video platform could get better test scores than those studying with textbooks. Regarding basic surgical skills, online teaching of suturing and knot-tying could be possible and was appreciated by the students who could practice away from the hospital and get feedbacks by instructors through online environment. The scores for the clinical competence assessment for incision, suturing and knot-tying were found to be no significant difference between the online teaching group and face-to-face teaching group. CONCLUSION: Online surgical curriculum for medical students is not easy but inevitable in the era of COVID-19 pandemic. Although online course is not the same as physical course, there are some efforts which could be tried to increase the effectiveness. Basic surgical skills could also be taught effectively through online platform. Even if the COVID-19 pandemic is over in the future, online curriculum could still be a helpful adjunct for surgical education.

Surgical Strategies for Cardiac Perforation After Catheter Ablation or Electrophysiology Study.

Catheter ablation is a treatment modality which has been increasingly used for cardiac arrhythmias. However, it is not complication-free, and cardiac perforation is one of its most life-threatening complications. As surgery is usually not the first-line treatment for this emergent episode, there were only very few sporadic surgical reports in the literature. This systemic review primarily aims to collect different surgical approaches for catheter-induced cardiac perforation to help surgeons manage this kind of uncommon and critical patients. Of the 452 initially screened articles, 22 studies (38 patients) were included in the systemic review. Of all the included patients, 84% (32/38) were found to have pericardial effusion acutely following catheter-related procedures, and 16% (6/38) experienced delayed-onset episodes. Regarding the surgical procedures, four patients underwent removal of clots only, eight patients underwent suture repair of the left ventricle (LV), nine patients underwent suture repair of the right ventricle (RV), five patients underwent suture repair of the LA, and four patients underwent sutureless repair of the LV and pulmonary vein (LV 1, RV 1, pulmonary vein 1). In addition to repair of perforation sites, the concomitant combined procedures included repair of intercostal vessels (complication of pericardiocentesis) for one patient, cryoablation for two patients, and maze procedure for one patient. For cardiac perforation following catheter ablation or electrophysiology study, although the majority of the patients are treated with pericardiocentesis and medical management at first, cardiovascular surgeons have to prepare to take over if the bleeding is persistent or if the cardiac tamponade is not relieved.

Veno-venous Extracorporeal Membrane Oxygenation for Right Ventricular Failure with Atrial Septostomy After Corrective Repair of Tetralogy of Fallot.

Right ventricular (RV) dysfunction may occur after cardiac surgery and it is not rare after corrective repair of tetralogy of Fallot (TOF). If traditional treatments with volume management, infusion of inotropic agents, and use of pulmonary vasodilators cannot stabilize the patient, extracorporeal membrane oxygenation (ECMO) or a ventricular assist device (VAD) will be considered as the last resort. Here, we report a young infant patient with RV failure after corrective repair of TOF and without closure of an atrial septal defect (ASD), who was rescued by veno-venous (VV) -ECMO.

Clinical experience of extracorporeal membrane oxygenation for acute respiratory distress syndrome associated with pneumonia in children.

BACKGROUND/PURPOSE: To describe a single center's experience with pediatric patients receiving extracorporeal membrane oxygenation (ECMO) for respiratory failure due to acute respiratory distress syndrome (ARDS) associated with pneumonia and to investigate the factors associated with mortality. METHODS: Retrospective chart review of all pediatric patients receiving ECMO for severe ARDS associated with pneumonia and sepsis from December 2001 to October 2009 in the pediatric intensive care unit (ICU) and cardiovascular surgery ICU at a tertiary medical center, to investigate the factors associated with mortality. RESULTS: Twelve patients had pneumonia and sepsis with progression to ARDS. The duration of intubation prior to ECMO was 19.92±10.40 hours. The duration of ECMO support was 241.08±194.93 hours. The range of PaO(2)/FiO(2) was 42-69.9, alveolar-arterial oxygen gradient (AaDO(2)) 602-645, and oxygenation index (OI) 27.4-68. The pre-ECMO intubation duration in the initial venoarterial ECMO group was significantly different from the venovenous ECMO group (9.4±10.93 vs. 151.25±152.16 hours). The overall survival to lung recovery rate was 66.7% (8/12) and survival to discharge rate 58.3%. The survival rate to lung recovery improved from 20% (between 2001 and 2003) to 100% (after 2004). Between the survival and nonsurvival groups, only ICU days and total intubated days were significantly longer in survivors. Although without statistical significance, the nonsurvivors tended to have lower white blood cell counts, higher C-reactive protein (CRP), and longer pre-ECMO intubation time. Seven of the 12 patients had bacterial pneumonia, higher CRP and creatinine values, and a lower hospital survival rate compared to the nonbacterial group (42.8% vs. 80%). CONCLUSION: Application of ECMO in pediatric patients with severe ARDS seems effective in improving survival, even under the conditions of pneumonia with septic shock.

Surgical or interventional treatment for adult patients with atrial septal defect and atrial fibrillation: A systemic review and meta-analysis.

The prevalence of atrial fibrillation (AFib) in adult patients with atrial septal defect (ASD) who did not undergo ASD repair in the childhood is higher than that in general population. The primary aim of this study is to collect various related articles published in the literature and to compare the clinical outcomes with different treatment strategies by systemic reviews and meta-analyses. Of the 1299 initially screened articles, 13 studies with 213 patients were included in this study. All the patients were adults and the mean age at presentation was 55.7 years (range 34-79 years) and 47.8% of the patients were male. Regarding the types of the AFib, there were paroxysmal AFib in 62 patients, persistent AFib in 40 patients and long-standing persistent AFib in 111 patients. For adult patients with ASD and AFib, ASD closure is beneficial for most of the patients if significant left-to-right shunt exists but risk stratification cannot be overlooked because worsening of the functional class may be experienced by some patients post-operatively, especially for the patients with advanced age (>75 years). Reduction of prevalence of AFib could be observed after ASD closure alone which is mainly effective for paroxysmal AFib but not for persistent or long-standing persistent AFib. The successful ablation rate of paroxysmal AFib by catheter ablation is similar to that of all kinds of AFib by surgical ablation. Regarding AFib recurrence, bi-atrial surgical ablation is better than right-atrial ablation for the adult patients with ASD and AFib.

Non-prompt surgery for patients with acute type A aortic dissection without pre-operative shock and malperfusion.

Background: Acute type A aortic dissection (ATAAD) requires urgent surgical treatment. However, during daily practice, there were some patients with ATAAD sought for medical attention several days after symptoms occurred and some other patients hesitated to receive aortic surgery after the diagnosis of ATAAD was made. This study aims to investigate the surgical outcomes of non-prompt aortic surgery (delayed diagnosis caused by the patient or delayed surgery despite immediate diagnosis) for ATAAD patients. Methods: From November 2004 to June 2020, of more than 200 patients with ATAAD patients who underwent aortic surgery at our hospital, there were 30 patients without pre-operative shock and malperfusion who sought for medical attention with symptoms for several days or delayed aortic surgery several days later despite ATAAD was diagnosed. Of the 30 patients (median age 60.9, range 33.4~82.5 years) in the study group, there were 18 patients undergoing surgery when they arrived at our hospital (delayed diagnosis by the patient) and 12 patients receiving surgery days later (delayed surgery despite immediate diagnosis). Patients with prompt surgery after symptom onset (control group) were matched from our database by propensity score matching. The surgical mortality rate and post-operative morbidities were compared between the study group and control group. Results: The in-hospital mortality was 3.3% for the study group and 6.7% for the control group (p = non-significant). The incidence of post-operative cerebral permanent neurological defect was 0% for the study group and 13.3% for the control group (p = 0.112). There were three patients receiving aortic re-intervention or re-do aortic surgery during follow-up for the study group and two patients for the control group. Conclusion: Prompt surgery for ATAAD is usually a good choice if everything is well prepared. Besides, urgent but non-prompt aortic surgery could also provide acceptable surgical results for ATAAD patients without pre-operative shock and malperfusion who did not seek medical attention or who could not make their minds to undergo surgery immediately after symptom onset. Hospitalization with intensive care is very important for pre-operative preparation and monitoring for the patients who decline prompt aortic surgery.

Retrograde cerebral perfusion for surgery of type A aortic dissection.

BACKGROUND: For type A aortic dissection (TAAD), antegrade cerebral perfusion (ACP) was proposed as a more physiological method than retrograde cerebral perfusion (RCP) for intra-operative brain protection, but it is still debatable whether antegrade cerebral perfusion (ACP) or retrograde cerebral perfusion (RCP) is related to the better clinical outcome. The present study was undertaken to compare the results in our patients receiving surgery for TAAD with ACP or RCP. The primary aim of this study was focused on the incidence of and the factors associated with surgical mortality, post-operative neurological outcomes and long-term survival. METHODS: From February 2001 to March 2019, there were 223 consecutive patients with TAAD treated surgically at our hospital. The median age at presentation was 56 years (range 29-88 years) and 70 patients (31.4%) over 65 years of age. There were 168 patients treated with RCP and 55 patients treated with ACP. The primary endpoints were surgical mortality and neurological outcome. Propensity score matching was used to compare the treatment results of surgeries with RCP or ACP. The long-term survival was also analyzed. RESULTS: The overall in-hospital mortality rate and the overall 30-day mortality rate were 15.6% and 14.3% respectively. For the patients without pre-operative shock (n = 184), the in-hospital mortality rate was 10.3% and the 30-day mortality rate was 8.7% and higher long-term survival rates (88.3% for 5 years, 86.5% for 10 years, 86.5% for 15 years) were documented for this patient group. There was no significant difference on the surgical mortality between the ACP group and the RCP group. In the entire cohort, there were 23 patients (10.3%) who suffered from post-operative neurological deficits (PND) and there were less PND for the patients with RCP than the patients with ACP (7.7% vs 18.1%, p = 0.027). After propensity score matching, there was still higher incidence of PND in the ACP group than in the RCP group but without statistical significance (18.5% vs 11.1%, p = 0.279). CONCLUSIONS: Aortic surgery carries high risk for the patients with TAAD and PND is not an unusual post-operative morbidity. In our series, pre-operative shock, pre-operative CPR, CRI, past history with CAD are related to higher surgical mortality. The younger patients (<65 years old) without pre-operative shock got better surgical outcome and long-term survival. RCP could provide acceptable cerebral protection during aortic surgery for the TAAD patients. Old age, pre-operative shock, CRI and past history of CAD are independent risk factors for long-term survival.

Coronary artery anatomy in complete transposition with situs solitus and dextrocardia.

The coronary artery anatomy of complete transposition with situs solitus/levocardia (CTSSL) has been well elucidated in the current era of arterial switch operation. However, coronary artery for complete transposition with situs solitus/dextrocardia (CTSSD) has never been documented. Coronary anatomy of transposition and aortopulmonary rotation were identified by angiography or surgical intervention from 1988 to 2007 at our hospital. The degree of aortopulmonary rotation was defined by the aortic sinus pattern on lateral angiogram. Apicocaval ipsilaterality was defined as situs solitus/dextrocardia or situs inversus/levocardia. The coronary artery anatomy in 3 cases of CTSSD was analyzed and correlated with those patients having transposition with the same coronary pattern but without apicocaval ipsilaterality, i.e., 276 cases with CTSSL and 8 cases with complete transposition with situs inversus/dextrocardia (CTSID). Fisher's exact test was used to determine statistical significance. All three cases with CTSSD (with apicocaval ipsilaterality) had a single coronary artery piercing into the left-hand sinus with a right coronary artery in the posterior atrioventricular groove, whereas all 284 cases without apicocaval ipsilaterality (CTSSL or CTSID) had the left circumflex artery in the posterior atrioventricular groove. The aorta was significantly less left laterally rotated in CTSSD than the other 2 cases of CTSSL and 3 cases of CTSSD with a similar coronary pattern (p < 0.05). One may anticipate coronary artery anatomy in the posterior atrioventricular groove based on apicocaval ipsilaterality, which in turn decreases aortopulmonary rotation to predict the central coronary pattern.

Staged surgical repair for infants with interrupted aortic arch.

BACKGROUND: Interrupted aortic arch (IAA) is a rare congenital cardiac anomaly, which necessitates surgical treatment. There are several surgical strategies for corrective repair of IAA, such as one-stage repair, rapid two-stage repair and two-stage repair. Here, we reported our surgical result of staged-repair policy for the patients with IAA. METHOD: From November 2003 to July 2015, there were 14 patients (8 boys, 6 girls) with IAA treated by us. Except one teenager patient, we routinely used intravenous infusion of prostaglandin E1 for all the infant patients (n = 13) to keep adequate end organ perfusion before the first surgical intervention. Surgical repair was performed after the perfusion of end organs recovered. RESULT: Two patients (1 teenager and 1 infant with one-stage surgery) were excluded from this study. At the time of the first surgery, we did the first-stage surgery with anastomosis in between aortic arch and descending aorta, division of patent ductus arteriosus and banding of pulmonary trunk through left thoracotomy. The overall surgical survival rate of the first surgery was 100% (12/12). At the time of the second surgery, corrective repair was done under cardiopulmonary bypass through median sternotomy. The surgical survival rate of the corrective surgery was also 100%. There is no late death during follow-up for 9 years (range 4.2-15.0 years). CONCLUSION: Out of several surgical strategies for the infants with IAA, staged repair still could be a treatment option to achieve satisfied surgical result.

Atrial gap junctions, NF-kappaB and fibrosis in patients undergoing coronary artery bypass surgery: the relationship with postoperative atrial fibrillation.

OBJECTIVES: We examined the role of atrial gap junctions, NF-kappaB and fibrosis in the occurrence of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: Forty-five patients with sinus rhythm were randomly assigned to the beating heart (n = 22) or cardioplegic cardiac arrest (n = 23) technique for surgery. Of them, 14 patients experienced post-CABG AF. Atrial samples taken before and after CABG surgery were analyzed. RESULTS: During surgery, Cx43 and Cx40 proteins were significantly reduced (both p < 0.05) in the arrested heart group, but only mildly decreased in the beating heart group. However, the change of either connexin was not associated with AF. In contrast, patients with AF had a higher baseline expression of NF-kappaB and more fibrosis compared to those without AF (both p < 0.05). CONCLUSIONS: CABG surgery with the beating heart technique attenuated the reduction of atrial Cx43 and Cx40 compared to the cardioplegic cardiac arrest technique. Atrial inflammation and fibrosis status before surgery, but not the changes of connexins during surgery, were associated with the occurrence of post-CABG AF.

Atropine use may lead to post-operative respiratory acidosis in neonates receiving ductal ligation: A retrospective cohort study.

BACKGROUND: Patent ductus arteriosus (PDA) is one of the most common cardiac conditions in preterm infants. Closure of the PDA in symptomatic patients can be achieved medically or surgically. Atropine is commonly administered in general anesthesia as a premedication in this age group but with limited evidence addressing the effect of its use. Our study examined the association of the use of atropine as a premedication in PDA ligation and the risk of post-operative respiratory complications. METHODS: This retrospective cohort study included 150 newborns who have failed medical treatment for PDA and received PDA ligation during 2008-2012 in a single tertiary medical center. Ninety-two of them (61.3%) received atropine as premedication for general anesthesia while 58 (38.7%) did not. Post-operative respiratory condition, the need of cardiopulmonary resuscitation and the presence of bradycardia were measured. RESULTS: Patients with atropine use were associated with increased odds of respiratory acidosis in both univariate analysis (22.9% vs 7.3%; OR = 3.785, 95% CI = 1.211-11.826, p = 0.022) and multivariate analysis (OR = 4.030, 95% CI = 1.230-13.202, p = 0.021), with an even higher odds of respiratory acidosis in patients receiving both atropine and ketamine. CONCLUSION: The use of atropine as premedication in general anesthesia for neonatal PDA ligation is associated with higher risk of respiratory acidosis, which worsens with the combined use of ketamine.

Morphologic substrates for first-branch pulmonary arterial hypoplasia in transposition of the great arteries.

BACKGROUND: Distal right-sided outflow obstruction remains a problem after arterial switch operation. We studied the anatomical features of the pulmonary trunk (PT) and its branches that are susceptible to right and left pulmonary arterial (RPA and LPA) hypoplasia in transposition of the great arteries (TGA). METHODS: One hundred and one angiograms of TGA performed between 1981 and 1996 were viewed, and Polaroid photos were taken at end-systole. The diameters of RPA, LPA, PT, duct, ascending aorta, and angles between PA and PT were measured, and the ductal flow direction was recorded. RESULTS: Forty-eight cases (47.5%) had a PA/PT diameter ratio (both PAs had same size) below 0.49. A smaller PA/PT was significantly related to posterior inclination of the proximal PT [narrower right (r = 0.50, p < 0.00001) and left (r = 0.48, p < 0.00001) PA-PT angle in lateral view] and a larger duct (r = 0.37, p < 0.0001). Eighteen patients had a follow-up angiogram after a mean period of 8.5 months. Those with a closed duct had evident PA growth (n = 12, 0.51 +/- 0.09 to 0.74 +/- 0.17, p < 0.0001), but four patients with an attenuated duct had no significant change (0.58 +/- 0.06 to 0.68 +/- 0.08, p = NS), and one with a persistent large duct had even regression of PA/PT (0.36-0.19). The direction of ductal flow was toward the aorta during early systole on cineangiogram. CONCLUSIONS: First-branch PA hypoplasia, which is frequently seen in TGA, was related to the right-to-left shunt through a duct resulting in hemodynamic starvation, and to posterior inclination of the proximal PT in this setting. Natural regression of the duct facilitated PA growth.