Gold Medal Forum Winner. Unfractionated heparin three times a day versus enoxaparin in the prevention of deep vein thrombosis in trauma patients.

Venous thromboembolic disease is a significant source of morbidity and mortality in hospitalized trauma patients. Multiple drugs and dosing regimens have been suggested for pharmacoprophylaxis. In this study, we compared efficacy, complications, and cost of unfractionated heparin administered subcutaneously three times a day with standard-dosed enoxaparin for prophylaxis of deep venous thrombosis (DVT) in adult trauma patients over 1 year. Patients admitted for greater than 72 hours who received pharmacoprophylaxis as part of a comprehensive DVT protocol were included. A change was made in the protocol from enoxaparin (30 mg twice a day or 40 mg per day) to heparin (5000 U three times a day) at midyear. Surveillance lower extremity venous ultrasound was performed according to established institutional guidelines. Data, including demographics, associated injuries, complications, and cost, were collected and analyzed. Four hundred seventy-six patients met inclusion criteria. Two hundred thirty-seven (49.8%) patients received enoxaparin and 239 (50.2%) received heparin. Proximal lower extremity DVTs were detected in 16 (6.75%) patients in the enoxaparin group and 17 (7.11%) in the heparin group (P = 0.999). Risk factors for DVT in these patients included spinal cord injury (P = 0.001) and closed head injury (P = 0.031). There was no difference between the incidence of pulmonary emboli and bleeding. There was an estimated yearly pharmacy cost savings of $135,606. In trauma patients, subcutaneous heparin dosed three times a day may be as effective as standard-dosed enoxaparin for prophylaxis of venous thromboembolism without increased complications. Heparin three times a day for venous thromboembolism prophylaxis was associated with significant pharmaceutical cost savings.

Rural surgery training: a survey of program directors.

BACKGROUND: Differences have been established between rural and urban surgery with regard to surgeon supply, demographics, and practices. This study attempts to determine the importance and prevalence of rural surgery training in American general surgery residency programs. STUDY DESIGN: A survey was electronically submitted to and completed by surgery program directors in the fall of 2004. Respondents were divided into research or nonresearch programs. Survey items measured attitudes toward the necessity and ideal components of a rural surgery curriculum and whether or not the program had such a curriculum in place. RESULTS: There was a 24.0% survey response rate, with 17.2% of respondents being classified as research programs. Research programs were less likely to believe that it was their mission to train rural surgeons (2.50 versus 4.36, p < 0.001) and were less likely to believe that a shortage of rural surgeons exists. Just over 36% of programs reported having a rural surgery curriculum. Programs that believed training rural surgeons was part of their mission and that believed such a curriculum was necessary to train rural surgeons were more likely to have a rural surgery curriculum in place. CONCLUSIONS: The presence of a curriculum to train rural surgeons is related to the belief that such a curriculum is necessary and that training rural surgeons is part of that residency program's mission. Residency programs have different attitudes and practices with regard to rural surgery training. Development of a rural surgery training designation can help trainees wishing to practice in a rural environment identify the programs best suited to equip them to do so.

Breast surgery techniques: preoperative bracketing wire localization by surgeons.

With the development of expertise in image guidance for breast surgery, many surgeons now perform preoperative wire localization themselves. Use of a single wire versus multiple wires to bracket a radiographic breast abnormality has previously been described, although benefits of this technique based on clinical outcomes such as margin status, tissue volume removed, and re-excision rates have not been established. This study is a retrospective analysis of wire-localized breast biopsies performed by 14 surgeons over 29 months; stereotactic and ultrasound guidance were used. During this time, 489 wire localizations were done, of which 159 used multiple wires. Two hundred eleven of these biopsies were done for malignant disease, 86 using multiple wires. After controlling for tumor node metastases stage, single and multiple wire placements were compared using endpoints of margin status, need for re-excision, and total volume of tissue removed. Neither margin status nor re-excision was related to the number of wires placed. However, the number of wires placed was significantly related to the total volume of tissue removed. Use of more than one localizing wire was associated with greater volume of tissue removal (measured in centimeters cubed) in benign disease (46 vs 25, P < 0.001), equivalent volumes in stage 0 disease (73 vs 67), less volume in stage 1 disease (113 vs 164), and less volume in stages 2 through 4 (158 vs 207, P = 0.03). Outcomes based on surgeon case volume during the study period demonstrated that low- (1-40), medium- (41-80), and high-volume (>80) surgeons did not differ in the type or stage of breast pathology treated. Surgeons with high case volumes were more likely to place multiple localizing wires (P < 0.001) and were more likely to do a breast-conserving procedure if re-excision was performed (P < 0.018). Surgeons with low case volumes were more likely to perform a re-excision (P < 0.025). Surgeon experience has a positive impact on quality outcome measures such as performance of a definitive procedure at the time of initial surgery and use of breast-conserving procedures at the time of re-excision. Multiple wire localization can be used to significantly reduce the volume of breast tissue removed in malignant disease without sacrificing margin status or increasing the need for future re-excision.

General surgery at rural Tennessee hospitals: a survey of rural Tennessee hospital administrators.

Rural communities face an impending surgical workforce crisis. The purpose of this study is to describe perceptions of rural Tennessee hospital administrators regarding the importance of surgical services to their hospitals. In collaboration with the Tennessee Hospital Association, we developed and administered a 13-item survey based on a recently published national survey to 80 rural Tennessee hospitals in August 2008. A total of 29 responses were received for an overall 36.3 per cent response rate. Over 44 per cent of rural surgeons were older than 50 years of age, and 27.6 per cent of hospitals reported they would lose at least one surgeon in the next 2 years. The responding hospitals reported losing 10.4 per cent of their surgical workforce in the preceding 2 years. Over 53 per cent were actively recruiting a general surgeon with an average time to recruit a surgeon of 11.8 months. Ninety-seven per cent stated that having a surgical program was very important to their financial viability with the mean and median reported revenue generated by a single general surgeon being $1.8 million and $1.4 million, respectively. Almost 11 per cent of the hospitals stated they would have to close if they lost surgical services. Although rural Tennessee hospitals face similar difficulties to national rural hospitals with regard to retaining and hiring surgeons, slightly more Tennessee hospitals (54 vs 36%) were actively attempting to recruit a general surgeon. The shortage of general surgeons is a threat to the accessibility of comprehensive hospital-based care for rural Tennesseans.

Video-assisted transumbilical appendectomy in children.

BACKGROUND: Video-assisted transumbilical appendectomy (VATA) is a combination of laparoscopic and open techniques and is not widely used in children. We are reporting our most recent experience with this technique. METHODS: After the institutional review board approval, the charts of patients who underwent VATA between December 2003 and October 2004 were retrospectively reviewed. All children presenting with a preoperative diagnosis of appendicitis were candidates. A 10-mm trocar was placed in the umbilicus. An operating laparoscope was used for mobilizing the appendix. The appendix was delivered through the umbilicus. A standard extracorporeal appendectomy was performed. The umbilical ring was closed and the wound irrigated. Demographic and outcome data were collected and is presented as mean +/- SD. RESULTS: Sixty-one males and 50 females underwent VATA (n = 111). Age and weight were 11 +/- 3.2 years and 49 +/- 22 kg, respectively. Six patients had previous abdominal surgery. Operative time was 36 +/- 24 minutes (range, 9-140 minutes). An additional trocar was placed in 2 patients, and 2 patients were converted to open. Five patients had additional procedures. Appendicitis was classified intraoperatively as acute (n = 44), suppurative (n = 5), gangrenous (n = 8), ruptured (n = 30), appendiceal colic (n = 13), and other (n = 11). Preoperative antibiotics were given to 95 patients and were continued in 35 patients postoperatively. Length of stay was 1.8 +/- 1.7 days (range, 1-11 days). Length of follow-up was 13 +/- 6.3 days (n = 90). Complications included intra-abdominal abscess (n = 1) and wound infection (n = 7). CONCLUSIONS: Video-assisted transumbilical appendectomy minimizes equipment needs, thus, potentially reducing cost. Simple and complex appendectomies can be performed even if the patient has had previous abdominal surgery. Our complication rate was low, and our operating times and length of stay were short. Video-assisted transumbilical appendectomy is a safe and effective technique in children and can be used in lieu of the 3-trocar laparoscopic technique.