Metabolic response 4 years after gastric bypass in a complete cohort with type 2 diabetes mellitus.

AIMS: To evaluate the long-term remission rates of type 2 diabetes mellitus and associated comorbidities after gastric bypass surgery in a complete cohort, in a real-life clinic setting. METHODS: A retrospective study of all consecutive patients with type 2 diabetes mellitus who underwent gastric bypass at a Veterans Affairs Medical Center from 2003 to 2010. The main outcome was remission of type 2 diabetes mellitus defined as HbA1c <6.5% (49 mmol/mol) without diabetic medication usage. Secondary outcomes were remission of hypertension and hyperlipidemia, weight loss, and long-term complications four years post-gastric bypass. RESULTS: Eighty-four patients with type 2 diabetes mellitus underwent gastric bypass. Four-year follow-up data were available for 92% (77/84) of patients. The patients (73% male; mean age 54 years) had a mean body mass index of 49 kg/m2 ±â€¯8.3. Hypertension and hyperlipidemia prevalence were 92% and 85%, respectively. The mean total body weight decrease over four years was 35 kg ±â€¯21. Remission of type 2 diabetes mellitus occurred in 15% at 6 months and 49% four years after surgery. Diabetes remission was more likely (OR 3.2; 95% confidence interval 1.2-9.7) in patients not using insulin at baseline. Remission rates were 12% (9/74) for hypertension and 16% (11/68) for hyperlipidemia. Long-term surgical complications included reoperation (11%), incisional hernia (10%) and anastomotic ulcer (10%). Forty-four percent of patients had one or more nutritional complications. CONCLUSIONS: The metabolic effects of gastric bypass are significant and durable for at least four years, even in a predominantly male cohort and real-life clinical setting.

Impact of seductive details on the acquisition and transfer of laparoscopic suturing skills: Emotionally interesting or cognitively taxing?

BACKGROUND: A common strategy to increase learner engagement is to interweave educational material with interesting but slightly tangential tidbits of information (eg, "war stories" and funny anecdotes), known as seductive details. Our objective was to examine the impact of seductive details on initial acquisition and transfer of basic laparoscopic surgical skills. METHODS: Novices (first- to fourth-year medical students) were randomized into control (N = 47) or seductive details (N = 42) groups. Curricula consisted of a baseline skills assessment (Fundamentals of Laparoscopic Surgery Task 1), instructional video on intracorporeal laparoscopic suturing (Fundamentals of Laparoscopic Surgery Task 5), multiple choice quiz, practice, and assessment on both primary and transfer tasks. Two separate instructional videos were used for Task 5; 20% of the seductive details group's instructional video consisted of seductive details, whereas the control group's video included no seductive details. Participants completed questionnaires of mental workload and task engagement after training. We also conducted a mediation analysis, which is a statistical approach to identify causal paths among a group of variables. RESULTS: Baseline skill scores (control: 112 ± 52; standard deviation: 118 ± 56; 0 = lowest possible score; 600 = highest possible score) and knowledge scores (control: 76 ± 19; standard deviation: 74 ± 16; 0 = lowest possible score; 100 = highest possible score) were similar for both groups. The control group demonstrated better (higher) performance on both the primary (434 ± 193 vs 399 ± 133, P < .05) and transfer (184 ± 74 vs 149 ± 91, P < .05) suturing tasks. Mental workload, as measured by the National Aeronautics and Space Administration-Task Load Index, was more demanding (higher) for the seductive details group (3.8 ± 0.5 vs 3.4 ± 0.7, P < .01; 1 = low workload; 5 = high workload) and was investigated as the possible mechanism by which group assignment impacted performance. Mediational paths using hierarchical regression were significant (P < .05), suggesting that trainees in the seductive details group performed worse because of their increased workload. CONCLUSION: Our findings suggest that the inclusion of seductive details may be detrimental to the acquisition and transfer of laparoscopic surgical skills due to increased mental workload for trainees.

Frame-of-reference training for simulation-based intraoperative communication assessment.

BACKGROUND: The purpose of this study was to examine the impact of frame-of-reference (FOR) training on assessments of intraoperative communication skills and identify areas of need to inform curricular efforts. METHODS: Simulation instructors (M.D., Ph.D., Research Fellow, Simulation Technician) underwent a 2-hour FOR training session with the operating room communication instrument. They then independently rated communication skills of 19 PGY1s who participated in a team-based simulation. Residents completed self-assessments via video review of the scenario. Intraclass correlation coefficients were used to examine inter-rater reliability. Relationships between trained raters and resident scores were assessed with Pearson correlation coefficients and paired sample t tests. RESULTS: Inter-reliability after FOR training was .91. The correlation between trained rater scores and resident evaluations was nonsignificant. Residents significantly underestimated their intraoperative communication skills (P < .05). Use of names, closed loop communication, and sharing information with team members demonstrated consistently low ratings among all residents. CONCLUSIONS: These findings reveal that a number of individuals can be trained to reliably rate resident intraoperative communication performance and that residents tend to under-rate their communication skills.

Different Goals, Different Pathways: The Role of Metacognition and Task Engagement in Surgical Skill Acquisition.

BACKGROUND: The purpose of this study is to understand why learning goals and performance goals may produce different outcomes in surgical skills training for novices, with specific attention to metacognition and task engagement. METHODS: Third-year medical students were randomized to a performance or learning-goal condition during a knot tying and suturing training program. Performance was assessed by blinded videotaped review. Demographics, goal orientation, and metacognition were captured with pre- and posttraining questionnaires. RESULTS: A total of 90 students participated in the training program. Trainees in the learning goals group demonstrated better performance on knot tying (4.30 ± 0.78 vs 3.86 ± 0.95; p < 0.05) and suturing (4.10 ± 0.77 vs 3.54 ± 0.73; p < 0.001). Participants in the learning goals group reported higher task engagement during both knot tying (4.32 ± 0.66 vs 3.90 ± 0.52; p < 0.001) and suturing (4.48 ± 0.42 vs 4.01 ± 0.46; p < 0.001). Additionally, the learning goals group also reported higher metacognition during both knot tying (3.88 ± 0.75 vs 3.59 ± 0.52; p < 0.05) and suturing (3.96 ± 0.75 vs 3.68 ± 0.48; p < 0.05). CONCLUSIONS: Our findings suggest that learning goals may be optimal for trainees learning new surgical tasks because they elicit increased task engagement and metacognition among trainees.

Duplicate appendix with acute ruptured appendicitis: a case report.

Duplication of the appendix is a rare congenital anomaly that, in adults, is most often found incidentally during surgery for other reasons. Appendicitis in the duplicated appendix is very rare and has been reported less than 10 times in the medical literature. We describe a 33-year-old woman with worsening periumbilical pain, nausea, vomiting, and fever. Physical examination showed localized peritonitis in the right lower quadrant. She had an elevated white blood cell count with neutrophilia. Computed tomography showed acute ruptured appendicitis. Diagnostic laparoscopy showed 2 appendices attached via separate bases to a single cecum with no other concurrent anomalies. Both appendices were removed laparoscopically. Histopathology confirmed normal appendiceal tissue in one and severe acute transmural appendicitis in the other. Awareness of appendiceal duplication and a thorough intraoperative inspection are critical to assess the presence of significant associated anomalies and avoid life-threatening complications.

Hepatic hydrothorax.

Hepatic hydrothorax is defined as a pleural effusion in patients with liver cirrhosis in the absence of cardiopulmonary disease. The estimated prevalence among patients with liver cirrhosis is approximately 5-6%. The pathophysiology involves the passage of ascitic fluid from the peritoneal cavity to the pleural space through diaphragmatic defects. The diagnosis is made from clinical presentation and confirmed by diagnostic thoracentesis with pleural fluid analysis. The initial medical management is sodium restriction and diuretics, but liver transplantation provides the only definitive therapy. For patients who are not transplant candidates and those who await organ availability, other therapeutic modalities that are to be considered include transjugular intrahepatic portosystemic shunt placement, videoassisted thoracoscopic surgery repair, pleurodesis, and vasoconstrictors (eg, octreotide and terlipressin). The primary therapeutic goals are to reduce ascitic fluid production and improve symptoms to bridge the time for liver transplantation.

Management of refractory ascites.

Ascites that does not respond or recurs after high-dose diuresis and sodium restriction should be considered refractory ascites. As cirrhosis advances, the escaping fluid overwhelms the lymphatic return. Decrease in renal plasma flow leads to increased sodium reabsorption at the proximal tubule leading to decreased responsiveness to loop diuretics and mineralocorticoid antagonists, which work distally. These complex hemodynamic alterations lead to refractory ascites. In refractory ascites, high-dose diuresis (400 mg of spironolactone and 160 mg of furosemide) and sodium restriction (<90 mmol/d) result in inadequate weight loss and sub optimal sodium excretion (<78 mmol/d). Further use of diuretics is limited by complications such as encephalopathy, azotemia, renal insufficiency, hyponatremia, and hyperkalemia. Therapy for refractory ascites is limited. The available therapies are repeated large volume paracentesis (LVP), transjugular intrahepatic portosystemic shunts, peritoneovenous shunts, investigational medical therapies, and liver transplantation. LVP with concomitant volume expanders is the initial treatment of choice. Transjugular intrahepatic portosystemic seems to be superior to LVP in reducing the need for repeated paracentesis and improves the quality of life. Several treatments that act at different steps in the pathogenesis of ascites are investigational, and some show promising results. Splanchnic and peripheral vasoconstrictors (Octreotide, Midodrine, and Terlipressin) increase effective arterial volume and decrease activation of the renin-angiotensin system with resultant increase in renal sodium excretion. Clonidine when given with spironolactone has been shown to cause rapid mobilization of ascites by significantly decreasing the sympathetic activity and renin-aldosterone levels. Natural aquaretics and synthetic V2 receptor antagonists (satavaptan) are being evaluated for mobilization of ascites by increasing the excretion of solute-free water. Liver transplantation remains the only definitive therapy for refractory ascites. Because refractory ascites is a poor prognostic sign, liver transplantation should be considered and incorporated early in the treatment plan.