A Pilot Study of Surgical Trainee Participation in Humanitarian Surgeries.

BACKGROUND: The impact of general surgery resident participation on operative case time and postoperative complications has been broadly studied in the United States. Although surgical trainee involvement in international humanitarian surgical care is escalating, there is limited information as to how this participation affects care rendered. This study examines the impact of trainee involvement on case length and immediate postoperative complications with regard to operations in low- and middle-income settings. METHODS: A retrospective chart review was conducted of humanitarian surgeries completed during annual short-term surgical missions performed by the International Surgical Health Initiative to Ghana and Peru. Between 2017 and 2019, procedures included inguinal hernia repairs and total abdominal hysterectomies (TAHs). Operative records were reviewed for case type, duration, and immediate postoperative complications. Cases were categorized as involving two attending co-surgeons (AA) or one attending and resident assistant (RA). RESULTS: There were 135 operative cases between 2017 and 2019; the majority (82%) involved a resident assistant. There were no statistically significant differences in case times between the attending assistant (AA) and resident assistant (RA) cohorts in both case types. All 23 postoperative complications were classified as Clavien-Dindo Grade I. In addition, resident assistance did not lead to a statistically significant increase in complication rate; 26% in the AA cohort versus 74% in the RA cohort (P = 0.3). CONCLUSIONS: This pilot study examining 135 operative cases over 2 y of humanitarian surgeries demonstrates that there were no differences in operative duration or complication rates between the AA and RA cohorts. We propose that surgical trainee involvement in low- and middle-income settings do not adversely impact operative case times or postoperative complications.

Factors Contributing to Extended Hospital Length of Stay in Emergency General Surgery†.

BACKGROUND: Emergency general surgery (EGS) is a field characterized by disproportionately high costs, post-operative mortality, and complications. We attempted to identify independent factors predictive of an increased postoperative length of stay (LOS), a key contributor to economic burden and worse outcomes. METHODS: The ACS-NSQIP database was queried for data from2005 to 2017. Current procedural terminology (CPT) codes were used to identify the most commonly performed EGS procedures: appendectomy, bowel resection, colectomy, and cholecystectomy. Cohorts above and below 75th percentile LOS were determined, compared by preoperative variables, and evaluated with univariate and multivariate logistic regression to quantify risk. RESULTS: Of 267,495 cases, 70,703 cases were above the 75th percentile for LOS. A larger proportion of patients in the extended LOS group were 41 years or older (88.6% vs 45.7%). More Blacks (10.3% vs 6.7%) were observed in the extended LOS group. Age, race, cardiopulmonary, hepatic, and renal disease, diabetes, recent weight loss, steroid use, and sepsis history were significant factors on multivariate analysis but varied in terms of risk proportion by procedure. Age (61+), Black race, hypertension, sepsis, and cancer were significant for all 4 procedures. CONCLUSIONS: Several factors are independently associated with extended LOS for those undergoing the most common EGS procedures. Five of these were associated with an increased LOS for all four procedures. These included, age (61+), hypertension, sepsis, cancer, and Black race.

Perioperative Advance Directives: Do Not Resuscitate in the Operating Room.

Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family's goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resuscitation for that individual patient.

Determination of Death in Execution by Lethal Injection in China.

Since 1997, execution in China has been increasingly performed by lethal injection. The current criteria for determination of death for execution by lethal injection (cessation of heartbeat, cessation of respiration, and dilated pupils) neither conform to current medical science nor to any standard of medical ethics. In practice, death is pronounced in China within tens of seconds after starting the lethal injection. At this stage, however, neither the common criteria for cardiopulmonary death (irreversible cessation of heartbeat and breathing) nor that of brain death (irreversible cessation of brain functions) have been met. To declare a still-living person dead is incompatible with human dignity, regardless of the processes following death pronouncement. This ethical concern is further aggravated if organs are procured from the prisoners. Analysis of postmortem blood thiopental level data from the United States indicates that thiopental, as used, may not provide sufficient surgical anesthesia. The dose of thiopental used in China is kept secret. It cannot be excluded that some of the organ explantation surgeries on prisoners subjected to lethal injection are performed under insufficient anesthesia in China. In such cases, the inmate may potentially experience asphyxiation and pain. Yet this can be easily overlooked by the medical professionals performing the explantation surgery because pancuronium prevents muscle responses to pain, resulting in an extremely inhumane situation. We call for an immediate revision of the death determination criteria in execution by lethal injection in China. Biological death must be ensured before death pronouncement, regardless of whether organ procurement is involved or not.

Pediatric Robot-assisted Redo Pyeloplasty With Buccal Mucosa Graft: A Novel Technique.

OBJECTIVE: To report a novel approach of pediatric robot-assisted redo pyeloplasty with buccal mucosa graft (BMG). METHODS: An Institutional Review Board-approved retrospective review of all patients undergoing robot-assisted redo pyeloplasty with BMG at our institution was performed. OPERATIVE DETAILS: For all patients, the following ports were used: one 8.5 mm camera, two 8 mm robotic, and one 5 mm assistant. Initial dissection was performed laparoscopically and robotically, and the ureter was incised longitudinally along the anterior surface. The robot was undocked, and BMG was harvested from the inner cheek. The robot was then redocked, and grafts were delivered via the 8 mm robotic port and anastomosed as anterior onlay grafts using 5-0 or 6-0 absorbable monofilament suture. Omentum was quilted over the graft as a vascular backing. Ureteral stents were placed intraoperatively and left in situ for 8 weeks. Foley catheters were removed on postoperative day 3. All patients received intravenous ampicillin and gentamicin preoperatively, with antibiotics discontinued within 24 hours. RESULTS: Three patients underwent robot-assisted redo pyeloplasty with BMG. Patient characteristics are seen in Table 1. Mean number of prior surgeries for ureteropelvic junction obstruction repair was 2 (1-3), and mean length of stricture was 4.3 cm (2.5-6). At a median follow-up of 10 months (5-26), all patients are asymptomatic with stable or improved ultrasound. CONCLUSION: Robot-assisted redo pyeloplasty with BMG is safe and feasible in the pediatric population. Long-term follow-up is needed to determine the durability of these grafts.

Critical analysis of laparoscopic donor nephrectomy in the setting of complex renal vasculature: initial experience and intermediate outcomes.

OBJECTIVE: We report our experience with laparoscopic donor nephrectomy (LDN) in the setting of complex renal vasculature and critically analyze the technique and intermediate recipient outcomes. METHODS: Thirty-nine living renal donors with multiple renal arteries or veins, or anomalous venous anatomy, who underwent LDN between 2003 and 2007 at our institution were retrospectively reviewed. Demographic and perioperative data were collected on donors and recipients. RESULTS: Complex vasculature consisted of multiple renal arteries in 26 cases (67%), multiple renal veins in 10 cases (26%), retroaortic renal vein in 5 cases (13%), circumaortic renal vein in 4 cases (10%), and a persistent left-sided inferior vena cava (IVC) in 1 case (3%). Thirty-four (87%) patients had a single anomaly and five (13%) had multiple anomalies. Mean operative time was 196.3 minutes (range 135-311 minutes), mean blood loss was 99.4 mL (range 25-400 mL), and mean hospitalization period was 2.6 days (range 1-4 days). Donor creatinine preoperatively and at discharge was 0.8 mg/dL and 1.2 mg/dL, respectively. Mean warm ischemia time was 168.9 seconds (range 90-300 seconds). Mean recipient creatinine at the time of discharge was 1.45 mg/dL, and nadir creatinine at 1 and 2 years follow-up was 1.41 mg/dL and 1.30 mg/dL, respectively. There were three (7.7%) intraoperative complications and two (5%) cases of allograft failure over the 2-year period. CONCLUSIONS: LDN in patients with complex vascular anatomy is safe and efficacious and does not negatively impact the complication rate or recipient outcomes. This procedure may improve the availability of allografts.