The degree of satisfaction and level of learning in male and female surgical residents: a nationwide questionnaire survey of graduating residents in Japan.

PURPOSE: Since 2002, the Japan Surgical Society has established a board certification system for surgeons to be certified for a specialty. Surgery remains a male-dominated field in Japan. This study aimed to clarify if the Japanese surgical residency training system is equally suitable for female and male residents. METHODS: The Japan Surgical Society conducted the first questionnaire survey regarding the system of surgical training for the residents in 2016. The questionnaire included the degree of satisfaction with 7 aspects of the training system, including the number and variety of cases experienced and duration and quality of instruction, and the learning level for 31 procedures. The degree of satisfaction and level of learning were compared between female and male residents. RESULTS: The degree of satisfaction was similar for all items between female and male residents. Female residents chose breast surgery as their subspecialty more frequently than male residents and were more confident in breast surgery procedures than male residents. Conversely, fewer female residents chose gastrointestinal surgery and were less confident in gastrointestinal surgery procedures than male residents. CONCLUSION: Female residents were as satisfied with the current surgical training system as male residents. However, there may be room for improvement in the surgical system, considering that fewer applications for gastrointestinal surgery come from female residents than from males.

Non-occlusive mesenteric ischemia after trans-catheter aortic valve implantation with thyroid storm: A case report.

Non-occlusive mesenteric ischemia (NOMI) is a rare but well-known life-threatening disease. However, reports on NOMI following trans-catheter aortic valve implantation (TAVI) are limited. This report presents a case of NOMI after trans-apical (TA) TAVI with thyroid storm. A 73-year-old man was admitted for a planned aortic valve surgery. Because he had severe aortic calcification and a right renal tumor that was suspected to be malignant, TA-TAVI was performed. At 61 h after TAVI, the patient complained of abdominal pain, and contrast-enhanced computed tomography showed ischemic necrosis of the cecum to the ascending colon. An ileocecal resection was performed emergently. He was extubated 61 h postoperatively, but severe delirium, high fever, and atrial fibrillation persisted. Due to a history of Basedow's disease, he was diagnosed with thyroid storm and treated with thiamazole and supportive care. The general status gradually improved, and he was transferred to the rehabilitation unit on the 17th postoperative day. We encountered a case of NOMI following TA-TAVI with a thyroid storm, which made it difficult to understand the patient's medical condition. Learning objective: The occurrence of non-occlusive mesenteric ischemia after trans-catheter aortic valve implantation is rare but possible, and a thyroid storm could occur even after a less invasive surgery. It is important to perform postoperative management while considering the possible occurrence of this condition.

First case of an invasive Bacteroides dorei infection detected in a patient with a mycotic aortic aneurysm-raising a rebellion of major indigenous bacteria in humans: a case report and review.

BACKGROUND: Bacteroides dorei is an anaerobic gram-negative bacterium first described in 2006. Because of the high similarity in mass spectra between B. dorei and Bacteroides vulgatus, discriminating between these species is arduous in clinical practice. In recent decades, 16S rRNA gene sequencing has been a complementary method for distinguishing taxonomically close bacteria, including B. dorei and B. vulgatus, at the genus and species levels. Consequently, B. dorei has been shown to contribute to some diseases, including type 1 autoimmune diabetes mellitus and atherosclerotic diseases. However, there are no reports on invasive infectious diseases caused by B. dorei. This report describes the first case of direct invasion and colonisation of human tissue by B. dorei, thus providing a warning regarding the previously proposed application of B. dorei as a live biotherapeutic for atherosclerotic diseases. CASE PRESENTATION: A 78-year-old Japanese man complained of intermittent chest/back pain and was diagnosed with a mycotic thoracic aortic aneurysm by enhanced computed tomography on admission. Despite strict blood pressure control and empirical antibiotic therapy, the patient's condition worsened. To prevent aneurysmal rupture and eliminate infectious foci, the patient underwent surgical treatment. The resected specimen was subjected to tissue culture and 16S rRNA gene sequencing analysis to identify pathogenic bacteria. A few days after the surgery, culture and sequencing results revealed that the pathogen was B. dorei/B. vulgatus and B. dorei, respectively. The patient was successfully treated with appropriate antibacterial therapy and after improvement, was transferred to another hospital for rehabilitation on postoperative day 34. There was no recurrence of infection or aneurysm after the patient transfer. CONCLUSIONS: This report describes the first case of invasive infectious disease caused by B. dorei, casting a shadow over its utilisation as a probiotic for atherosclerotic diseases.

Is there disparity between regions and facilities in surgical resident training in Japan? Insights from a national survey.

PURPOSE: This study sought to assess the disparity between regions and facilities in surgical resident training in Japan via a national level needs-assessment. METHODS: A survey was sent to all 909 graduating residents of 2016. Residents trained in the six prefectures with a population of 7 million or more were included in the large prefecture (LP) group. Residents trained in the other 41 prefectures were included in the small prefecture (SP) group. Each group was further divided into a university hospital (UH) group and a non-university hospital (NUH) group. RESULTS: The response rate was 56.3% (n = 512). Excluding nine residents who did not report their prefectures and facilities, surveys from 503 residents were analyzed. The UH group received significantly more years of training. In the SP and UH groups, there were significantly fewer residents who had performed 150 procedures or more under general anesthesia in comparison to the LP and NUH groups, respectively. Self-assessed competencies for several procedures were significantly lower in the SP and UH groups. CONCLUSION: Disparity in surgical resident training was found between regions and facilities in Japan. The surgical residency curriculum in Japan could be improved to address this problem.

Are graduating residents sufficiently competent? Results of a national gap analysis survey of program directors and graduating residents in Japan.

PURPOSE: To evaluate the self-assessed competency of graduating residents (GRs) in Japan upon completion of their residency and to identify the gap between their competency and the competency expected by their program directors (PDs). METHOD: A list of 31 essential surgical procedures was compiled according to the consensus of surgical educators from around the country. A survey with this list was sent to all 909 GRs and their 611 PDs in 2016. The GRs rated their competency to perform these procedures and the PDs were asked to evaluate the expected competency of their GRs using the Zwisch Scale. RESULT: The response rate was 56.3% for the GRs and 76.8% for the PDs. Fewer than half of the GRs who responded felt confident performing ten (32%) of the surgical procedures evaluated. For most procedures, the GRs' self-reported competency was lower than the expectation reported by their PDs. This gap was more than 10% for 13 of the procedures. CONCLUSION: More than half of the GRs in Japan lacked the confidence in their skill to perform one-third of the surgical procedures selected for evaluation in this study. These findings should be used to update the surgical education curriculum in Japan.

Progression of vascular remodeling in pulmonary vein obstruction.

OBJECTIVES: Pulmonary vein obstruction (PVO) frequently occurs after repair of total anomalous pulmonary vein connection with progression of intimal hyperplasia from the anastomotic site toward upstream pulmonary veins (PVs). However, the understanding of mechanism in PVO progression is constrained by lack of data derived from a physiological model of the disease, and no prophylaxis has been established. We developed a new PVO animal model, investigated the mechanisms of PVO progression, and examined a new prophylactic strategy. METHODS: We developed a chronic PVO model using infant domestic pigs by cutting and resuturing the left lower PV followed by weekly hemodynamic parameter measurement and angiographic assessment of the anastomosed PV. Subsequently, we tested a novel therapeutic strategy with external application of rapamycin-eluting film to the anastomotic site. RESULTS: We found the pig PVO model mimicked human PVO hemodynamically and histopathologically. This model exhibited increased expression levels of Ki-67 and phospho-mammalian target of rapamycin in smooth muscle-like cells at the anastomotic neointima. In addition, contractile to synthetic phenotypic transition; that is, dedifferentiation of smooth muscle cells and mammalian target of rapamycin pathway activation in the neointima of upstream PVs were observed. Rapamycin-eluting films externally applied around the anastomotic site inhibited the activation of mammalian target of rapamycin in the smooth muscle-like cells of neointima, and delayed PV anastomotic stenosis. CONCLUSIONS: We demonstrate the evidence on dedifferentiation of smooth muscle-like cells and mammalian target of rapamycin pathway activation in the pathogenesis of PVO progression. Delivery of rapamycin to the anastomotic site from the external side delayed PV anastomotic stenosis, implicating a new therapeutic strategy to prevent PVO progression.

Maximization of the sealing effect of fibrin glue in aortic surgery.

OBJECTIVES: Fibrin glue is used to reinforce anastomosis in aortic surgery. There has not yet been a consensus on how it should be applied optimally. This study aimed to define the optimal condition of applying fibrin glue. METHODS: In experiment 1, we determined the optimal condition for spraying fibrin glue using an expanded polytetrafluoroethylene graft within a needle hole. The length and area of the fibrin cap within the hole were measured. In experiment 2, methods for applying fibrinogen were assessed by comparing brushing and spraying. In experiment 3, swine aorta segments sutured with a Dacron graft were divided into the following three groups: nothing was applied; fibrinogen was sprayed and rubbed using brush. The aorta was clamped and blood was infused from an occlusion catheter inserted into the graft. The pressure at the first appearance of blood leak was recorded. RESULTS: In experiment 1, among the four groups divided by the pressure and distance of spraying, the fibrin cap area in the group with 0.075 MPa and 2-cm spray distance was significantly larger than that in the group with 0.15 MPa and 2 cm (P < 0.01). In experiment 2, the fibrin cap area in the brushing group was significantly larger than that in the spraying group (P < 0.05). In experiment 3, the capacity to resist endoluminal pressure was higher in the brushing and combined spraying group compared with that in the sequential combined spraying group (P < 0.01). CONCLUSIONS: The brush and spray methods showed excellent hemostatic outcomes.

Left Subclavian-Bilateral External Carotid Artery Bypass for Symptomatic Carotid Artery Dissection Secondary to Open Repair of Type A Aortic Dissection.

Symptomatic carotid dissection, secondary to surgical repair of Stanford type A acute aortic dissection (AAD), requires prompt intervention. A 56-year-old man who underwent total arch replacement with frozen elephant trunk for AAD presented with left hemiplegia and unilateral spatial neglect 16 h after the surgery. Cerebral computed tomography (CT) revealed no fresh lesions, and CT angiography showed severe bilateral carotid dissection. The patient's neurological symptoms improved soon after left subclavian-bilateral external carotid artery bypass to correct symptomatic severe right cerebral ischemia. Therefore, this technique can be a good option for symptomatic carotid dissection in selected patients.

A snapshot of surgical resident training in Japan: results of a national-level needs assessment survey.

PURPOSE: To evaluate the status of surgical training in Japan through a national-level needs assessment. METHODS: A survey was sent to all 909 graduating residents (GRs) and their 611 program directors (PDs) for the year 2016. A working group of surgical educators from around the country was formed under the education committee of the Japan Surgical Society. The survey items were developed by consensus of this working group. The survey investigated the knowledge and problems of the current curriculum, and the status of the current residency training. RESULTS: The response rates were 56.3% of the GRs and 76.8% of the PDs. Among the participants, 47.6% of the GRs and 29.4% of the PDs believed that the residency curriculum did not match the clinical experience. Over 80% of the GRs and PDs agreed on the importance of training outside of the OR, whereas only 13% of the GRs had received such training regularly. Trainees also reported a lower satisfaction rate about the opportunity to train outside of the OR. CONCLUSION: This national-level needs assessment of surgical training in Japan identified several gaps in the curriculum. These results provide valuable data to assist the ongoing efforts for surgical residency curriculum improvement.

A novel diagnostic system for Doppler ultrasound of the peripheral arteries to detect the presence of thoracic aortic aneurysm.

OBJECTIVE: We aimed to develop a novel ultrasound system and examine its feasibility for noninvasively detecting thoracic aortic aneurysm (TAA) in clinical settings. METHODS: We developed a novel ultrasound system consisting of a modified console and data analysis algorithm. The exploratory study included 100 patients hospitalized for elective cardiovascular surgery. After admission, the arterial pulse waveform at the left carotid artery was acquired using the novel system. Based on these data, we inferred the presence of TAA based on arterial viscoelasticity and instability, which are reflected into the time-averaged trajectory of deformation of the blood vessel wall caused by disturbance of blood flow. Meanwhile, all patients underwent computed tomography as preoperative screening to confirm the presence of TAA. The sensitivity and specificity of TAA detection using the novel ultrasound system were calculated. RESULTS: The datasets from 37 patients were not suitable for analysis and were thus discarded. Based on computed tomography findings, 40 patients were categorized into the aneurysm group while 23 were judged not to have and aortic aneurysm. On the other hand, 44 patients were diagnosed as having TAA based on ultrasound findings obtained using the novel system. The overall sensitivity and specificity of the ultrasound system were 0.83 and 0.52, respectively. CONCLUSION: We successfully developed a novel system for noninvasive, ultrasound-based evaluation of the left carotid artery to detect TAA. Although improvements to the probe and diagnostic algorithm are warranted, this device has potential utility for mass screening to detect asymptomatic TAA as part of community-level healthcare programs.

Differential selective hypothermic intercostal artery perfusion: a new method to probe spinal cord perfusion during thoracoabdominal aortic aneurysm repair.

OBJECTIVE: To prevent paraplegia in patients undergoing thoracoabdominal aortic aneurysm repair, the importance of preoperative identification of the Adamkiewicz artery and reconstruction of critical intercostal artery have been advocated. Conversely, significance of collateral network for spinal cord perfusion has been recognized. We invented a new system consisting of a direct monitoring of cerebrospinal fluid temperature (CSFT) and differential selective hypothermic intercostal artery perfusion (D-HIAP). METHODS: After exposing a critical intercostal artery, a 10-mm prosthetic graft was anastomosed in an end to side fashion. A balloon-tipped catheter was inserted into the graft to perfuse with 15 °C blood. Neighboring intercostal arteries were also perfused in the same fashion. Serial monitoring of CSFT was performed. Between January 2011 and January 2015, D-HIAP was employed in 50 patients with Adamkiewicz artery that located within a reconstructed area. RESULTS: Significant CSFT drop was recorded after initiation of D-HIAP in 42 (84%) patients. Of those, 34 (68%) patients showed significantly lowered CSFT with D-HIAP into a single critical intercostal artery. Perfusion into plural intercostal arteries was necessary for CSFT drop in 2 cases (4%), and plural intercostal artery perfusion further enhanced CSFT drop that had been modestly achieved by single intercostal artery perfusion in 6 cases (12%). Eight (16%) patients did not exhibit a significant drop in CSFT even when D-HIAP was employed for the critical and neighboring intercostal arteries. CONCLUSIONS: The detection of a disparity in temperature between the intrathecal space and blood generated by D-HIAP revealed individual variability in CSFT changes, which may imply a complexity in spinal cord perfusion. Intraoperative D-HIAP may help to identify a major blood supply for spinal cord perfusion and underlying collateral network.

[Aortic Root Pseudoaneurysm due to Avulsion of Aortic Valve Commissure Following to Infective Endocarditis;Report of a case].

A 40-year-old man presented to our hospital with fever and slight palpitation. The echocardiogram revealed bicuspid aortic valve, massive aortic regurgitation, and aneurysm of Valsalva sinus. Operative findings showed an aortic root pseudoaneurysm originating just below the avulsion of the right to left commissure. The orifice was closed with a part of a woven vascular graft, and the aortic valve was replaced with a mechanical valve. There was no sign of marked inflammation, although pathophysiologic findings indicated infective endocarditis. His postoperative course was uneventful.

Left Ventricular Blood Flow Dynamics In Aortic Stenosis Before And After Aortic Valve Replacement.

Surgical intervention for aortic valve stenosis (AS) has been established; however its diagnosis based on echocardiographic assessment is still limited by aortic valvular velocity, aortic valvular pressure gradients, and color Doppler imaging. Echo-dynamography (EDG) is a method to determine intracardiac flow dynamics, such as two-dimensional blood flow velocity, vortex, and dynamic pressure. These flow dynamics may be influenced by left ventricular (LV) wall motion and the resistance in LV outflow caused by AS. The objective of the present study was to assess the changes and differences in LV vortices and vorticity before and after AS surgery. Five patients who underwent aortic valve replacement surgery for AS and five control patients were included. Besides routine echocardiographic measurement, EDG was applied to determine the two-dimensional blood flow vector and vorticity. The LV vortex flow in the isovolumetric contraction phase had multiple formations in preoperative cases. The clockwise vortex was found in all cases postoperatively; the vortex formation showed no significant difference between postoperative and normal control groups. EDG may serve important information on LV flow dynamics, non-invasively.

[Latest Monitoring Systems for Vital Signs in Cardiothoracic Surgery].

In this review article, the latest monitoring systems for vital signs in cardiothoracic surgery, including a multi-wavelength pulse oximeter, a transcutaneous blood gas monitoring system, a modified pulmonary artery catheter, and modern less-invasive cardiac output measurement systems are introduced. These less-invasive and real-time/continuous monitoring technologies would provide useful information for perioperative care after cardiothoracic surgeries, and improve the outcomes of surgeries.

Association between the severity of acquired von Willebrand syndrome and gastrointestinal bleeding after continuous-flow left ventricular assist device implantation.

OBJECTIVES: Acquired von Willebrand syndrome, characterized by the reduction in von Willebrand factor (vWF) large multimers, has recently been considered as one of the causes of gastrointestinal bleeding (GIB). It remains unclear whether its haematological severity is linked with susceptibility to bleeding because the definition of the haematological severity of acquired von Willebrand syndrome has not been precisely determined. This study sought to establish a quantitative methodology to assess the haematological severity of acquired von Willebrand syndrome and to define the threshold for occurrence of GIB in patients implanted with left ventricular assist devices (LVADs). METHODS: In total, 41 patients treated with continuous-flow LVAD implanted between 2011 and 2017 at Tohoku University Hospital were investigated. vWF large multimers were quantitatively evaluated using the 'vWF large multimer index' defined as the ratio of a large multimer proportion in total vWF derived from a patient to that from a normal control. Using this index, the amount of vWF large multimers was expressed as a percentage of its normal control value obtained with a simultaneous analysis of each time measurement. RESULTS: Twelve (29%) patients developed GIB events during follow-up periods (median 591 days) after an LVAD implantation. The vWF large multimer index in patients with GIB was significantly lower than that in those without GIB (25.0 ± 10.3% vs 37.5 ± 17.8%, P = 0.008). Most importantly, all patients experiencing GIB exhibited a vWF large multimer index below 40%. CONCLUSIONS: Patients with GIB exhibited a more severe loss of vWF large multimers. The vWF large multimer index may dictate the risk of GIB after an LVAD implantation. Clinical trial registration number: UMIN000018135.

Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial.

OBJECTIVES: Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD. METHODS: This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset. RESULTS: Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03). CONCLUSIONS: Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.