Effects of In-House Calls on Medical Students' Perspectives of Surgical Education and Future Career Opportunities.

Background: It has been shown that surgical residents who took few or no in-house calls during medical school felt less prepared for the residency. In this study, our objective was to assess the impact of in-house calls carried out by medical students on their perceptions of medical training, including the influence on specialty choice. Methods: The students were asked to complete an anonymized questionnaire at the first and last day of their general surgery clerkship. Students were asked regarding importance for medical training and education, preparation for the internship, learning opportunities, skills acquisition; negative effects, including fatigue, negative effect over medical training, personal life, and physical and mental health derangements; and the student's perception of the residents' in-house calls and parameters affecting specialty selection: difficulty of the residency, prestige, and future career opportunities. Results: A total of 42 medical students responded to 84 questionnaires. There was a significant difference in the importance of calls among male students before the beginning of the clerkships compared with the end of the clerkship (4.53 versus 4.21, P = .034). At the end of general surgery clerkship, students indicated that the calls less impaired studying during the clerkship (2.5 versus 2.21, P < .05) compared with the beginning of the clerkship. Female students ranked the calls as less demanding at the end of the clerkship (2.53 versus 2.12, P < .05). The impact of the residency difficulty on the selection of their future specialty was rated higher by the students at the end of the clerkship compared with their expectations at the beginning (3.13 versus 2.85, P = .033). Conclusions: In conclusion, our study demonstrates that in-house calls performed by medical students during their general surgery clerkships have a significant influence on their perceptions of medical training and choice of specialty. The study also highlights the importance of gender differences in the students' perception of the importance and impact of calls on their well-being.

Single liver metastasis of a follicular variant of papillary thyroid carcinoma: a rare pattern of organ spread.

SUMMARY: Well-differentiated thyroid cancer (WDTC), including papillary, follicular, and Hurthle-cell types, is characterized by a slow course and usually remain localized to the thyroid. However, a minority of these cases develop distant metastases with the most common sites being lungs, bones, and lymph nodes. Liver metastases of WDTC are rare and are usually found along with other distant metastases sites and in a multiple or diffuse pattern of spread. The recognition of distant metastasis in WDTC has a significant impact on the treatment and prognosis. However, because of their low incidence and awareness, distant metastases are often diagnosed late. Herein, we describe a case of a 71 years old woman who during routine surveillance of a follicular variant of papillary thyroid cancer (FV-PTC), 5 years after being treated for her primary thyroid tumor, was found to have a single liver metastasis and underwent liver segmental resection. This case highlights the importance of maintaining vigilant surveillance of patients with WDTC, and illustrates the possibility of unique metastasis at unexpected sites. Further studies are needed to understand the organ tropism of some WDTC leading to distant metastases development and to better prediction of an aggressive course. LEARNING POINTS: WDTC patients with distant metastases have a poor prognosis with a 10-year survival of about 50%. The most common sites of distant metastases are lung, bone and lymph nodes. Liver metastases are rare in WDTC, are usually multiple or diffuse and are found along with other distant metastases sites. Single liver metastasis of WDTC is an unexpected pattern of spread, and very few cases are reported in the literature. Rare sites of distant metastases in WDTC can manifest many years after the primary tumor, stressing the importance of maintaining vigilant surveillance. More studies are needed to predict which WDTC tumors may develop a more aggressive course, allowing clinicians to individualize patient management.

Accuracy and inter-operator variability of small bowel length measurement at laparoscopy.

BACKGROUND: Measurement of bowel length is an essential surgical skill for laparoscopic and open gastrointestinal surgery in order to achieve favorable outcomes and avoid long-term complications. Variations in accuracy between the two surgical approaches may exist. However, only few studies have tried to assess these differences. Our aim was to assess reliability and inter-rater variability of small bowel length assessment during laparoscopy in an in vivo porcine model. METHODS: This is a single-institution, double-blinded, technical assessment study in a porcine in vivo model. Fourteen participants (ten senior surgeons with >1000 laparoscopic procedures and four junior surgeons) had to assess and mark lengths of small bowel in both laparoscopic and open surgical approaches. Each participant was assigned to measure and mark specific, randomized distances (range 25-197 cm) in both laparoscopic and open approaches using color-coded vessel loops. Actual participant-marked distances were compared to the assigned distances followed by Bland-Altman plots and linear regression analysis to determine accuracy and proportional error trends. Study data were further compared to available data sets from previously published studies. RESULTS: Laparoscopy measurements were significantly shorter than required (difference 33.8 ± 28.7 cm, P < 0.001, 95% CI 17.8-49.7). The measuring error was proportional to the length of the measured segment (63% of the required distances, IQR 58.9-79.0%, P = 0.02). At laparotomy, mean difference and standard deviation were lower (1.5 cm ± SD 15 cm) and not statistically significant (P = 0.7). Re-analysis of previously published data sets validated the observed errors in laparoscopic bowel measurement (P < 0.01). CONCLUSIONS: Small bowel length assessment during laparoscopy is inaccurate and associated with substantial variability. There is a need to develop a standardized laparoscopic technique for measuring small bowel length which is simple, reproducible, and easy to learn.

Laparoscopic subtotal gastrectomy for gastric cancer.

BACKGROUND: The use of laparoscopy in the treatment of gastric malignancy is still controversial. However, several reports suggest that the laparoscopic approach may be safe and applicable. The aim of this study was to review our experience with laparoscopic gastrectomy for gastric malignant tumors amenable to subtotal gastrectomy, and assess the oncologic outcome. METHODS: The laparoscopic approach to subtotal gastrectomy was selected according to both the surgeon's and patient's preference. Data regarding demographics, operative procedures, postoperative course, and follow-up were prospectively collected in a computerized database. Survival data were obtained from the national census. RESULTS: Twenty patients were operated on, 18 for gastric adenocarcinoma, one for gastric lymphoma, and one for gastrointestinal stromal tumor. There were 10 males and 10 females, mean age of 67. D1 subtotal gastrectomy with Billroth-2 reconstruction was performed. Mean operative time was 335 minutes. Tumor-free margins were obtained in all cases, and a mean of 15 lymph nodes were retrieved. Median postoperative hospital stay was 12 days. Postoperative complications included leak from the duodenal stump (2), intraabdominal abscess (2), anastomotic leak (1), wound infection (1), and bowel obstruction (1); re-operation was required in 4 patients. No perioperative mortality occurred in our series. Pathology showed nodal involvement in 8 patients. During a mean follow-up of 39 months, 4 patients expired from recurrent and metastatic disease; all had positive lymph nodes. The Kaplan-Meier calculated 5-year survival was 79%. CONCLUSION: Although a challenging and lengthy procedure, laparoscopic subtotal gastrectomy yields acceptable surgical and oncologic results that may further improve with increased surgeon experience. Thus, the application of laparoscopy in the surgical treatment of distal gastric malignancy may be considered; however, further data are needed before this approach can be recommended.

Laparoscopic partial splenectomy using radiofrequency ablation.

INTRODUCTION: Epidermoid cysts are believed to be congenital in origin and often present in the pediatric population. Because of the concerns of compromised immunologic function after total splenectomy and increasing demand for minimally invasive approaches, interest has increased in performing the partial splenectomy in this patient population by laparoscopic techniques. Nonetheless, concerns for adequate hemostasis have limited its widespread adoption. Because radiofrequency ablation for the partial splenectomy has been done in a laparoscopic porcine model with good results, we used this technology with the goal of limiting blood loss and postoperative hemorrhagic complications. CASE REPORT: A 25-year-old female presented with complaints of right shoulder pain. Abdominal ultrasound and a computed tomography (CT) scan revealed a 10-cm cystic lesion of the spleen. Serology was negative for hydatid cyst pathology. The patient underwent an uneventful partial splenectomy by minimally invasive techniques with the aid of a laparoscopic radiofrequency ablative device and the placement of a hemostatic medicated sponge along the line of transection. RESULTS: Estimated blood loss was less than 30 mL. Final pathology was consistent with an epidermoid splenic cyst, and the patient was discharged uneventfully on postoperative day 5. DISCUSSION: Techniques for the treatment of symptomatic splenic cysts range from total splenectomy to cyst fenestration and placement of the omentum in the splenic defect. The use of radiofrequency ablation has been traditionally used for hepatic parenchymal transection but seems equally suited for the partial splenectomy. This technology, and the addition of hemostatic sponges, seems to provide excellent results in minimizing blood loss, intraoperatively and postoperatively, during the laparoscopic partial splenectomy; however, randomized, prospective trials will be necessary to see if they will be superior to traditional techniques.

Totally laparoscopic extended left hepatectomy.

This video will discuss the main steps necessary to perform a totally laparoscopic extended left hepatectomy including partial or complete resection of the middle hepatic vein and resection of segment I. Although totally laparoscopic extended liver resections are currently only being performed in several centers with experience in both minimally invasive and hepatobiliary surgery, it will likely become more common, as more surgeons gain expertise in both of these disciplines.

Low incidence of adhesion-related bowel obstruction after laparoscopic colorectal surgery.

BACKGROUND: Postoperative adhesions are a major cause of morbidity, accounting for approximately 5% of the readmissions of surgical patients. Bowel obstruction is attributed to adhesions in more than half of the cases, many of which are following colon and rectal surgery. Laparoscopic surgery has the potential advantage of reduced adhesion formation owing to attenuated surgical trauma, less tissue handling, and smaller scars. However, the translation of these advantages to a reduced rate of bowel obstruction has not been sufficiently demonstrated. The aim of this study was to assess the rate of adhesion-related bowel obstruction after laparoscopic colon and rectal surgery. METHODS: Data regarding all cases of laparoscopic colon and rectal surgery were prospectively collected. Information relative to demographics, surgical procedures, and follow-up was analyzed, and patients who were readmitted for bowel obstruction were identified. RESULTS: Over a period of 8 years, 306 patients, at a mean age of 63 years, had a laparoscopic colon and rectal operation in our department-122 for benign conditions and 184 for malignant disease. The mean length of follow-up was 38 months. Six cases (2%) of bowel obstruction, which were unrelated to hernia or advanced cancer, were identified. Two patients had a history of open surgery, in addition to the laparoscopic procedure, so adhesions could be attributed solely to the laparoscopic procedure in 4 patients, which consisted of 1.3% of the total study group. Obstruction occurred within 2 weeks of surgery in 2 patients, and one early reoperation was required. CONCLUSIONS: The incidence of adhesion ileus after laparoscopic colon and rectal surgery appears to be very low. This long-term benefit of laparoscopic surgery should be considered when comparing this technique to its open counterpart.

Late regeneration of infarcted small bowel mucosa: a case report.

Ischemic injury of the small bowel may recover after revascularization, provided that full-thickness infarction did not occur. Animal studies showed that if the mucosal crypts remain viable, rapid mucosal restitution occurs hours after injury. The treatment of transmucosal infarction that does not extend to full wall thickness, however, was not investigated thoroughly. The patient presented had a mesenteric event leading to resection of about half of his small bowel. The unresected segment had severe ischemic injury, which seemed to cause transmucosal, but not transmural, infarction. Imaging of the remaining small bowel revealed a seromuscular layer denuded of mucosa. The ischemic damage was too deep to allow rapid regeneration, and the patient had short-bowel syndrome. A year later, during operation for stricture complications, new mucosa covered parts of the small-bowel surface, encouraging the surgeon to elect a conservative approach. Sixteen months after the injury, normal mucosa covered the entire small bowel, and enteral feeding resumed successfully. This report shows that infarcted small-bowel mucosa may regenerate even months after injury.

[Novel approach to parathyroid adenoma: minimally invasive, focused, scan guided parathyroidectomy--experience from the first 100 cases].

BACKGROUND: Traditionally, the surgical approach to parathyroid adenoma included formal bilateral neck exploration, inspection and evaluation of all four glands. Recently, following progress in the precision of pre-operative localization by sonography and scintigraphy and the availability of a real time PTH assay, focused, minimally invasive approaches to the removal of a single adenoma were proposed. We review our experience in the first 100 cases. METHOD: After localization of the suspected adenoma by TC-99m-MIBI scintigraphy and neck sonography, a second scan was performed just before surgery and the presumed site was marked on the patients skin. Under general anesthesia, via a limited incision, the suspected adenoma was excised and examined by a frozen section. RESULTS: Between July 1999 and August 2001, 97 patients (64 females and 33 males, mean age; 56 +/- 14, range 19-88) underwent 100 focused, minimally invasive, MIBI guided parathyroidectomies (3 patients were operated on twice due to a residual second adenoma). Pre-operative blood levels of calcium and PTH were 11.5 +/- 0.8 mg/dl and 140 +/- 90 pg/ml, respectively. In 93 cases, an adenoma was identified and excised (mean weight, 600 mg, range, 100-4900). Mean operative time, including frozen section was 66 +/- 39 minutes. The patients were discharged on the same day or on POD 1 (mean calcium level 9 +/- 0.9 mg/dl) and had normal calcium levels at the follow-up tests. In 2 cases, the scan was falsely negative for adenoma (positive for other thyroid pathology), but the adenoma was successfully excised according to the sonographic localization (overall success rate in the primary procedure, 95%). In 3 cases, pathologically proven enlarged parathyroid was excised, as localized by the scan, but hypercalcemia relapsed. The patients were re-operated in a focused fashion and a residual second adenoma was found (N = 2), or underwent formal exploration for hyperplasia of the remaining 3 glands (N = 1). In 2 more cases, no parathyroid tissue was found in the specimen. However, consequently, calcium levels normalized after surgery (N = 1) and a successful focused re-operation was performed after relocalization (N = 1). There were no significant post-operative complications. CONCLUSIONS: Focused MIBI guided parathyroidectomy is safe and efficient in most patients. Failures, which may be the results of erroneous diagnosis (hyperplasia vs. adenoma, 1%), residual additional adenoma (2%) or a false positive scan due to pathology in the thyroid gland (2%), can be treated safely and effectively in a second focused procedure.

[The laparoscopic treatment of gallstone ileus].

The laparoscopic approach to abdominal emergencies, including bowel obstruction, has recently become more prevalent. A gallstone, entering the bowel through a cholecysto-enteric fistula, is a rare cause of bowel obstruction. The laparoscopic management of gallstone ileus has been described, but mostly as a laproscopic-assisted procedure, with a limited abdominal incision to treat the obstructed bowel. We describe a case in which we used a totally laparoscopic approach to treat gallstone ileus.

Colon and rectal surgery without mechanical bowel preparation: a randomized prospective trial.

OBJECTIVE: To assess whether elective colon and rectal surgery can be safely performed without preoperative mechanical bowel preparation. SUMMARY BACKGROUND DATA: Mechanical bowel preparation is routinely done before colon and rectal surgery, aimed at reducing the risk of postoperative infectious complications. However, in cases of penetrating colon trauma, primary colonic anastomosis has proven to be safe even though the bowel is not prepared. METHODS: Patients undergoing elective colon and rectal resections with primary anastomosis were prospectively randomized into two groups. Group A had mechanical bowel preparation with polyethylene glycol before surgery, and group B had their surgery without preoperative mechanical bowel preparation. Patients were followed up for 30 days for wound, anastomotic, and intra-abdominal infectious complications. RESULTS: Three hundred eighty patients were included in the study, 187 in group A and 193 in group B. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. Colo-colonic or colorectal anastomosis was performed in 63% of the patients in group A and 66% in group B. There was no difference in the rate of surgical infectious complications between the two groups. The overall infectious complications rate was 10.2% in group A and 8.8% in group B. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.4%, 3.7%, and 1.1% versus 5.7%, 2.1%, and 1%, respectively. CONCLUSIONS: These results suggest that elective colon and rectal surgery may be safely performed without mechanical preparation.