Evolution of lesion-specific management of blunt thoracic aortic injury.

Developments in diagnosis and treatment have transformed the management of blunt thoracic aortic injuries (BTAIs). For patients in stable condition, treatment practice has shifted from early open repair to nonoperative management for low-grade lesions and routine delayed endovascular repair for more significant injuries. However, effective therapy depends on accurate staging of injury grade and stability to select patients for appropriate management. Recent developments in BTAI risk stratification enable lesion-specific management tailored to the patient and aortic lesion. This review summarizes advances in lesion assessment and treatment and proposes an integrated scheme for the modern management of BTAI.

An educated guess - Distance estimation by surgeons.

INTRODUCTION: Estimating distance is a common task in surgery, yet development of distance estimation ability receives little attention in surgical training. Although the Small bites versus large bites for closure of abdominal midline incisions (STITCH) trial reinforced the importance of suture spacing by demonstrating reduced incisional hernia incidence in placement of 5-mm fascial sutures over 1 cm, we hypothesize that neither trainee nor attending surgeons possess the ability to estimate these distances with accuracy. METHODS: We distributed a 4-question distance estimation exercise and a 6-question survey to resident and attending surgeons at a single academic medical center. The mean and the absolute error were compared using a t test. RESULTS: Most participants were trainees (44 vs 16 attendings, N = 60), and 27% used the metric system prior to undergraduate studies. The mean absolute errors for 5-mm and 1-cm mark placement were 1.40 and 2.07 mm, respectively. The 5-mm mark placement estimates ranged from 2.01 to 11.69 mm, and the 1-cm estimates ranged from 4.82 to 19.19 mm. There was no statistically significant difference in the estimates or absolute errors between trainees and attendings (5 mm P = .202; 1 cm P = .302). CONCLUSION: These findings suggest that estimation of distance is a challenge, and development of this fundamental skill during surgical training may have important clinical consequences.

Clinical response to combination therapy in the treatment of varicose veins.

BACKGROUND: Varicose vein ablation procedures are being performed with increasing frequency; however, there is a lack of consensus on the relative efficacy of combined treatment of saphenous incompetence and symptomatic varicosities vs a staged approach. In this study, we examined the impact on symptom severity when a procedure to eliminate varicosities was added to standard endovenous saphenous ablation. METHODS: The Varicose Vein Module of the American Venous Registry was established by the American Venous Forum in 2010 and collected data from 48 physicians during a 5-year period. We analyzed patients with Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) C2 disease severity and without prior treatment. Combination therapy (CT) was defined as the use of a procedure directly addressing visible varicosities (stab phlebectomy or injection of sclerosant into varicosity) combined with endovenous saphenous vein ablation. Unimodal therapy (UT) was defined as endovenous saphenous vein ablation alone (radiofrequency or laser). Change in symptom severity was assessed by the pretreatment and 1-month follow-up Venous Clinical Severity Score (VCSS). Univariate statistics compared the CT and UT groups, with P values obtained using the Student t-test or Pearson χ2 test as appropriate. A multivariable linear regression model assessed the association of CT with the change in VCSS. RESULTS: There were 526 patients included for analysis (UT, 97; CT, 429). UT patients were more likely to be white (85.6% vs 62.7%; P < .001), had a higher initial VCSS (6.71 vs 5.07; P < .001), and were assessed at an earlier follow-up visit (28.9 days postoperatively vs 33.3 days; P < .001). Compared with UT, CT was associated with an additional half-point reduction in VCSS on univariate analysis (-3.71 points for UT vs -4.20 for CT; P = .13). After treatment, CT was associated with significantly lower scores on the pain and varicose vein components of the VCSS (pain: 0.31 for UT vs 0.07 for CT [P = .0008]; varicose veins: 0.47 for UT vs 0.03 for CT [P < .001]). On the multivariable model, after adjustment for white race, day of follow-up, age group, and initial VCSS, CT was associated with an additional reduction in VCSS of 1.52 points compared with UT (P = .002). CONCLUSIONS: Invasive treatment of C2 chronic venous insufficiency improves symptom severity. Whereas treatment of venous reflux is essential to address venous symptoms, our results suggest that patients further benefit from additional direct treatment of varicosities. For selected patients, CT may present a more effective treatment strategy than saphenous ablation alone.

Residents' Experience in Breast Cancer Care.

OBJECTIVE: General surgeons commonly treat breast cancer (BC), hence necessitating adequate training during residency. We examined surgery residents' exposure to these conditions across postgraduate years (PGYs) to assess the proximity of involvement to commencement. STUDY DESIGN: We examined the BC operative profile by PGY using the American College of Surgeons National Surgical Quality Improvement Program Participant Use File (ACS NSQIP PUF, 2008-2011). Operations were classified using the Surgical Council on Resident Education curriculum complexity categories. Univariate analysis was performed using chi-square, Fisher exact, analysis of variance, and Kruskal-Wallis tests, as appropriate. RESULTS: Of 58,413 BC operations, 23,996 involved PGY1 to PGY5 residents. A Surgical Council on Resident Education complexity was assigned to 97.7% of operations studied (n = 23,432). PGY was inversely proportional to the number of operations performed. PGY1 to PGY3 residents covered most essential-common operations (PGY1-3, 72% vs PGY4-5, 28%; p < 0.001). PGY1 and PGY2 residents covered more than half of the complex operations (PGY1-2, 55% [n = 359] vs PGY3-5, 45% [n = 288]; p = 0.033). CONCLUSIONS: Although junior residents perform most of the BC cases in surgical residency, residents do participate in operations for BC across the continuum of the training years. Program directors should consider trainees' career aspirations to ensure adequate exposure to the operative and nonoperative management of this common disease before the transition to independent practice.

Rescue pyloroplasty for refractory delayed gastric emptying following esophagectomy.

BACKGROUND: Delayed gastric emptying (DGE) following esophagectomy is a debilitating complication. Rarely, failure of postoperative endoscopic therapy may necessitate rescue pyloroplasty (rPP). METHODS: We conducted a retrospective, single-institution review of rPP for post-esophagectomy DGE from 2000 to 2013. Pre- and postoperative symptoms and pharmacologic use were examined. "Successful" rPP was defined as resolution of symptoms and pharmacologic requirements postoperatively. Quality of life (QoL) was evaluated by Short Form-12 and study-specific questionnaires. RESULTS: Thirteen patients underwent open transabdominal rescue Heineke-Mikulicz pyloroplasty. Between esophagectomy and rPP, average interval weight loss was 19 ± 15 lb over 13 months (range, 3-22). Patients underwent 3.4 ± 1.0 preoperative endoscopic balloon dilation (EBD) attempts, with 7 (54%) receiving endoscopic intrapyloric botulinum toxin (IPB) injections. Median follow-up was 12 months (range, 4-23). After rPP, the incidence of nausea, vomiting, bloating, prokinetic use, and total parenteral nutrition/total enteral nutrition dependence decreased (all P < .01). All patients gained weight; 2 developed biliary reflux. Nine of 13 patients were identified as rPP successes; predictors of rPP failure were American Society of Anesthesiologists grade 3 (P = .02), greater number of EBD attempts (P = .02), longer time to rPP (P = .03), and fewer IPB injections (P = .03). QoL assessment revealed general satisfaction with postoperative outcomes and excellent physical and mental functioning. CONCLUSION: rPP for post-esophagectomy DGE is well-tolerated, results in improvements in symptoms and pharmacologic dependence, and satisfactorily preserves QoL.