Surgical experience and identification of errors in laparoscopic cholecystectomy.

BACKGROUND: Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS: Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS: Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION: This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

An AIDS-defining neoplasm in a 30-year-old man on highly active antiretroviral therapy: a forgotten diagnosis?

Highly active antiretroviral therapy (HAART) has dramatically improved the morbidity and mortality of patients with HIV. Although the incidence of AIDS-defining neoplasms is decreasing with this therapy, they must still be considered in patients who present with suspicious symptoms. Early diagnosis and treatment may help to improve quality of life and clinical outcome. We report the case of a 30-year-old man on HAART who presented with an expanding lump in the left groin, thought to be a haematoma for 5 months. A high level of suspicion led to a prompt diagnosis of Burkitt's lymphoma followed by timely treatment with chemotherapy. This culminated in complete remission, with an improved quality of life.

Temporary sacral nerve stimulation alters rectal sensory function: a physiological study.

BACKGROUND: The indications for sacral nerve stimulation are increasing, but the mechanism remains poorly understood. OBJECTIVE: This study aimed to examine the effect of sacral nerve stimulation on rectal compliance and rectal sensory function. DESIGN: This was a prospective study. SETTINGS: This study took place at a university teaching hospital. PATIENTS: Twenty-three consecutive consenting patients (22 female; median age, 49 y) undergoing temporary sacral nerve stimulation for fecal incontinence were prospectively studied. Clinical response was assessed by the use of bowel diaries and Wexner scores. MAIN OUTCOME MEASURES: Anal manometry, rectal compliance, volume and pressure thresholds to rectal distension (barostat), and rectal Doppler mucosal blood flow were measured before and at the end of stimulation. RESULTS: Sixteen patients (70%) had a favorable clinical response. Median anal squeeze pressures increased with stimulation from 40 (range, 6-156) cmH2O to 64 (range, 16-243) cmH2O. Median rectal compliance did not significantly change with stimulation (prestimulation: 11.5 (range, 7.9-21.8) mL/mmHg, poststimulation: 12.4 (range, 6.2-22) mL/mmHg, P = .941). Rectal wall pressures associated with urge (baseline: 15.4 (range, 11-26.7) mmHg, poststimulation: 19 (range, 11.1-42.7) mmHg, P = .054) and maximal tolerated thresholds (baseline: 21.6 (8.5-31.9) mmHg, poststimulation: 27.1 (14.3-43.3) mmHg, P = .023) significantly increased after stimulation. Rectal Doppler mucosal blood flow did not significantly change with stimulation (baseline: 125.8 (69.9-346.8), poststimulation: 112.4 (50.2-404.1), P = .735). Changes in anal resting pressure and rectal wall pressures with stimulation were evident only in responders; however, changes in anal squeeze pressures were evident in both responders and nonresponders. LIMITATIONS: The study reports results following short-term stimulation in a small but homogenous group of patients. A larger long-term study will follow. CONCLUSION: Temporary sacral nerve stimulation does not change rectal compliance, but is associated with significant changes to the pressure thresholds of rectal distension. This, together with the observation that outcome is not related to sphincter integrity, supports the hypothesis of an afferent-mediated mechanism of action.

Laparoscopic nonresectional suture rectopexy in the management of full-thickness rectal prolapse: substantive retrospective series.

BACKGROUND: Numerous surgical options exist for the correction of rectal prolapse, with the optimal choice remaining controversial. The laparoscopic approach has proved to be popular and effective. Concern exists about nonresectional rectopexy in the form of intractable postoperative constipation. The authors present their experience with nonresectional laparoscopic suture rectopexy. METHODS: All patients presenting with a full-thickness rectal prolapse between August 1994 and August 2009 who proved to be fit for a general anesthesia were offered a laparoscopic repair. Data were entered into a database, then prospectively and retrospectively analyzed. The data recorded included patient demographics, preoperative symptoms, conversion to open procedure, length of hospital stay, and postoperative complications. Preoperative Cleveland Clinic Incontinence Scores (CCIS) were calculated. Follow-up evaluation was by telephone questionnaire. Postoperative constipation, recurrence, and CCIS were noted. RESULTS: The series included 72 patients (71 women, 98%) with a median age of 72 years (range, 24-88 years). The median follow-up period was 48 months (range, 5-144 months). A total of 13 patients were lost to follow-up evaluation. The median operating time was 98 min (range, 35-200 min), and the median hospital stay was 2 days (range, 1-29 days). Three conversions to open procedure (5%) were performed. The median preoperative CCIS was 9.54 compared with 4.44 postoperatively (p = 0.024). The complications included one postoperative bleed requiring transfusion, one port-site abscess requiring incision and drainage, one postoperative retention of urine, and one chest infection. Postoperatively, 10 patients (17%) reported occasional constipation not requiring intervention, and an additional 10 patients (17%) reported more severe constipation, all managed successfully with regular laxatives. The patients followed up experienced six recurrences (9%). No postoperative deaths occurred. CONCLUSION: Laparoscopic abdominal suture rectopexy without resection is safe and effective for the treatment of full-thickness rectal prolapse.

Yersinia enterocolitica infection in a patient with hemachromatosis masquerading as proximal colon cancer with liver metastases: report of a case.

A patient with genetic hemachromatosis presented with a clinical picture suggesting malignancy and CT evidence of lesions in the right colon and liver. Colonoscopy failed to confirm the suspected diagnosis. Blood and stool cultures were positive for yersinia enterocolittica infection. This case illustrates the need to confirm clinically and radiologically suspected malignancy. It also serves as a model of how localized gastrointestinal pathology can result from the interaction of host genetic factors and specific microbial species.

Electromyographic biofeedback can improve subjective and objective measures of fecal incontinence in the short term.

Electromyographic biofeedback therapy has demonstrated subjective improvement in patients with fecal incontinence that is comparable to surgery. We assessed the efficacy of biofeedback therapy in a consecutive heterogeneous group of patients using both subjective and objective assessment criteria. These 28 patients with fecal incontinence were studied retrospectively. Patients were assessed using a quality-of-life questionnaire (QOL), the Vaizey and Wexner incontinence scoring systems, and anorectal manometry for efficacy of treatment, before and after biofeedback therapy. Eighty-six percent of patients completed the study. Median follow-up was 18 months. Eighty percent of patients demonstrated significant improvements in their Vaizey and Wexner scores (P<0.001 and P<0.001, respectively). The mean QOL score improved from 62 to 77 (P<0.01). Significant improvements were also demonstrated in the mean resting pressure (P<0.01), peak amplitude of squeeze (P<0.01), and the duration of squeeze pressure (P<0.05). The deferred 15-minute evacuation time also significantly increased (P<0.001). This study reported significant short-term improvement in fecal incontinence with electromyographic biofeedback therapy using validated subjective and objective scoring systems. Similarly, this treatment also significantly improved anorectal manometric findings. Our data confirm the role of biofeedback therapy in the multimodality approach to patients with fecal incontinence.

Dynamic magnetic resonance imaging of the pelvic floor in patients with idiopathic combined fecal and urinary incontinence.

The etiologies of combined fecal and urinary incontinence may be interrelated but remain poorly understood. A potential variable in this process is global pelvic floor dysfunction. The aim of this study was to prospectively assess the use of phased-array, body coil dynamic MRI in identifying pelvic floor abnormalities in patients with combined incontinence symptoms. Symptomatic patients were compared to asymptomatic control subjects and were selected from those referred to the pelvic physiology laboratory with complaints of combined urinary and fecal incontinence. All patients underwent standard urodynamic studies and anorectal physiologic assessment. Colonoscopy and endoanal ultrasonography were also performed. A standardized protocol was used for dynamic MRI, and the parameters were measured using workstation software (callipers, compass, and densitometer). In the incontinent group there was a significant difference, when compared to control subjects, in the angle of the levator ani muscle arch of the levator plate complex (3.0+/-5 degrees vs. 14+/-10 degrees; P=0.004), the width of the levator hiatus (58.3+/-8 mm vs. 46.5+/-8 mm; P=0.001), the area and tissue density of the levator ani muscle (19.5+/-1 mm(2) vs. 26.9+/-1 mm(2); P=0.001, and 157.3+/-47 pixels vs. 126.1+/-23 pixels; P=0.025, respectively), and in the length of the external anal sphincter (20.0+/-5 mm vs. 26.6+/-13 mm; P=0.03). Body coil dynamic MRI is a noninvasive and well-tolerated imaging modality. Our data show that it can identify changes in pelvic muscle morphology in patients with disorders of incontinence, and this may help in planning better management strategies.