Sleep deprivation among surgical residents: Does it affect performance while practising a laparoscopic intestinal anastomosis?

INTRODUCTION: To assess the impact of fatigue due to incorrect night rest in the performance of a laparoscopic manual anastomosis. METHODS: A prospective study evaluating the results from the realization of a manual endotrainer entero-enteral anastomosis performed by residents in terms of fatigue caused by inadequate nightly rest. Two groups were established; the FATIGUE group (F): anastomosis performed by residents coming off shift who slept less than seven hours and the REST group(R), being those who slept at home for more than 7 h. The time taken, length of the anastomosis and quality of such were compared based on 4 parameters: Air leak test, correct tension on the suture line, accurate opposition of the edges and optimal distance between stitches. RESULTS: 402 anastomoses were studied (211 rest group, 191 fatigue group). In the fatigue group leaks were detected in 33.5% anastomoses, as opposed to 19.4% in the rest group (P < .01). El rest group performed the anastomosis in 56.75 min and the fatigue group in 61,49 min (P = .006). There were no significant differences in the others parameters. CONCLUSIONS: Fatigue increases the risk of leakage and the time to do the exercise.

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Prediction of post-idroidectomy hypocalcemia through rapid PTH determination. / Predicción de hipocalcemia postiroidectomía mediante determinación de PTH rápida.

INTRODUCTION: Hypocalcemia is the most frequent complication after thyroidectomy. The aim of this work is to identify biochemical risk factors of hypocalcemia using quick perioperative (pre and post-thyroidectomy) intact parathyroid hormone (PTHi) and postoperative calcemias. METHODS: In a consecutive series of 310 total thyroidectomies, samples of quick PTHi at the anaesthetic induction and 10 minutes after surgery, together with serum calcemias every 12 hours were obtained. The sensitivity, specificity, positive and negative predictive value are analyzed and related to hypocalcemia. A control group of hemithyroidectomies is also analyzed to compare the effects of surgery on PTH secretion. RESULTS: Of the 310 patients, 202 (65.1%) remained normocalcemic and asymptomatic (group A), 108 (34.9%) presented hypocalcemia (Group B), requiring oral calcium (79 symptomatic). After analysis of several cut-off points, combining a PTHr drop gradient of 60% or calcemia inferior to 7.4 mg/dl at 24 hours, a sensitivity of 100% is achieved without leaving false negatives. Compared to the control group, there is a significant difference with respect to the post-operative calcemias and PTHr, p < 0.001. CONCLUSIONS: Total thyroidectomy affects parathyroid function with evident decrease in rPTH and risk of hypocalcemia. The combination of PTHr decrease of 60% or less than 7.4 mg/dl calcemia at 24 hours gives a 100% sensitivity for predicting patients at risk of hypocalcemia.

Analysis of learning styles in a laparoscopic technical skills course. Implications for surgical training. / Análisis de los estilos de aprendizaje en un curso de habilidades técnicas laparoscópicas. Implicaciones para el entrenamiento quirúrgico.

INTRODUCTION: Learning surgical techniques is a dynamic process. In the 1980s David Kolb described developed a learning model that enabled teaching styles to adapt for better learner outcomes. The aim of this study was to identify the Kolb learning styles of the participants in a laparoscopic technical skills course and to check see if there was any relationship with performance. METHODS: An observational descriptive study was conducted with 64 participants in an intensive course in which they performed laparoscopic manual intestinal anastomoses. All completed Kolb's inventory of learning styles. For each anastomosis, join quality was assessed and the performing time recorded. After that, they were analyzed through statistical studies. RESULTS: The most frequent learning style was assimilating type (39.1%). No significant differences were observed between different learning styles and gender, professional category, the time taken or the quality of the anastomoses. CONCLUSIONS: Assimilating type was the most frequent Kolb learning style, with no differences observed between categories, age or gender. There is no relationship between the learning style of the participants and the results obtained in the course.

Influence of previous experience on the benefits of laparoscopic surgical training based on simulation. / Influencia de la experiencia previa en los beneficios del entrenamiento quirúrgico laparoscópico basado en la simulación.

INTRODUCTION: Surgical training based on simulation seeks the acquisition of skills in novice participants and ongoing sill development in experts. The aim of this study is to assess the evolution of students in an intensive laparoscopic anastomosis course and to analyse their results depending on their level and previous experience. METHODS: The students of all the anastomosis courses conducted during 30 months in the Valdecilla virtual hospital (Santander) were analysed. Manual side-to-side intestinal anastomoses with porcine 'ex vivo' viscera were performed in a laparoscopic endotrainer. The technical and quality differences between the first and the last anastomoses were analyzed and the progression between residents and specialists was compared. RESULTS: We analyzed 45 participants, 22 of them residents and 23 specialists. A statistically significant improvement of 80.5% was observed in all procedural parameters (94.8% residents vs. 67.3% specialists). The time was reduced by 48.1% in the residents and 43.2% in the specialists (p<.001). In terms of quality, significant improvements were obtained in the group of residents: an increase of 90% in adequate tension, and a reduction of 75% of everted edges and 60% of leaks. In addition, they obtained results comparable to the specialists (27.3% leak in the last anastomosis vs. 34.8% by the specialists, p=.59), which presented improvement without statistical significance. CONCLUSIONS: The group of residents presented a major and significant improvement in procedural skills and in the quality of the technique, reaching the level of the specialists after completion of the course.

Increased Expression Profile and Functionality of TLR6 in Peripheral Blood Mononuclear Cells and Hepatocytes of Morbidly Obese Patients with Non-Alcoholic Fatty Liver Disease.

Current evidence suggests that gut dysbiosis drives obesity and non-alcoholic fatty liver disease (NAFLD) pathogenesis. Toll-like receptor 2 (TLR2) and TLR6 specifically recognize components of Gram-positive bacteria. Despite the potential implications of TLR2 in NAFLD pathogenesis, the role of TLR6 has not been addressed. Our aim is to study a potential role of TLR6 in obesity-related NAFLD. Forty morbidly obese patients undergoing bariatric surgery were prospectively studied. Cell surface expression of TLR2 and TLR6 was assessed on peripheral blood mononuclear cells (PBMCs) by flow cytometry. Freshly isolated monocytes were cultured with specific TLR2/TLR6 agonists and intracellular production of cytokines was determined by flow-cytometry. In liver biopsies, the expression of TLR2 and TLR6 was analyzed by immunohistochemistry and cytokine gene expression using RT-qPCR. TLR6 expression in PBMCs from non-alcoholic steatohepatitis (NASH) patients was significantly higher when compared to those from simple steatosis. The production of pro-inflammatory cytokines in response to TLR2/TLR6 stimulation was also significantly higher in patients with lobular inflammation. Hepatocyte expression of TLR6 but not that of TLR2 was increased in NAFLD patients compared to normal liver histology. Deregulated expression and activity of peripheral TLR6 in morbidly obese patients can mirror the liver inflammatory events that are well known drivers of obesity-related NASH pathogenesis. Moreover, TLR6 is also significantly overexpressed in the hepatocytes of NAFLD patients compared to their normal counterparts. Thus, deregulated TLR6 expression may potentiate TLR2-mediated liver inflammation in NAFLD pathogenesis, and also serve as a potential peripheral biomarker of obesity-related NASH.

Laparoscopic and robot-assisted laparoscopic digestive surgery: Present and future directions.

Laparoscopic surgery is applied today worldwide to most digestive procedures. In some of them, such as cholecystectomy, Nissen's fundoplication or obesity surgery, laparoscopy has become the standard in practice. In others, such as colon or gastric resection, the laparoscopic approach is frequently used and its usefulness is unquestionable. More complex procedures, such as esophageal, liver or pancreatic resections are, however, more infrequently performed, due to the high grade of skill necessary. As a result, there is less clinical evidence to support its implementation. In the recent years, robot-assisted laparoscopic surgery has been increasingly applied, again with little evidence for comparison with the conventional laparoscopic approach. This review will focus on the complex digestive procedures as well as those whose use in standard practice could be more controversial. Also novel robot-assisted procedures will be updated.

[Management of spontaneous hepatic hemorrhage due to focal nodular hyperplasia]. / Manejo terapéutico de la hemorragia espontánea hepática debido a una hiperplasia nodular focal.

Focal nodular hyperplasia is a benign liver tumor that usually follows an asymptomatic course. Hemorrhage of hepatic focal nodular hyperplasia is exceptional and occurs in tumors such as hepatocellular carcinoma and hepatic adenoma. We report the case of a woman with spontaneous rupture and hemorrhage of focal nodular hyperplasia. Hemodynamic stabilization was achieved by selective hepatic arterial embolization. Elective hepatic resection was subsequently performed. This clinical course is extremely rare. We describe the therapeutic management of these complications using hepatic transarterial embolization, which could avoid potentially harmful aggressive treatments.