The impact of laparoscopic bariatric workshops on the practice patterns of surgeons.

BACKGROUND: This study was designed to evaluate the impact of a 2-day laparoscopic bariatric workshop on the practice patterns of participating surgeons. METHODS: From October 1998 to June 2002, 18 laparoscopic bariatric workshops were attended by 300 surgeons. Questionnaires were mailed to all participants. RESULTS: Responses were received from 124 surgeons (41%), among whom were 56 bariatric surgeons (open) (45%), 30 advanced laparoscopic surgeons (24%), and 38 surgeons who performed neither bariatric nor advanced laparoscopic surgery (31%). The questionnaire responses showed that 46 surgeons (37%) currently are performing laparoscopic gastric bypass (LGB), 38 (31%) are performing open gastric bypass, and 39 (32%) are not performing bariatric surgery. Since completion of the course, 46 surgeons have performed 8,893 LGBs (mean, 193 cases/surgeon). Overall, 87 of the surgeons (70%) thought that a limited preceptorship was necessary before performance of LGB, yet only 25% underwent this additional training. According to a poll, the respondents thought that, on the average, 50 cases (range, 10-150 cases) are needed for a claim of proficiency. CONCLUSION: Laparoscopic bariatric workshops are effective educational tools for surgeons wishing to adopt bariatric surgery. Open bariatric surgeons have the highest rates of adopting laparoscopic techniques and tend to participate in more adjunctive training before performing LGB. There was consensus that the learning curve is steep, and that additional training often is necessary. The authors propose a mechanism for post-residency skill acquisition for advanced laparoscopic surgery.

Repair of ventral hernias in morbidly obese patients undergoing laparoscopic gastric bypass should not be deferred.

BACKGROUND: There is no consensus regarding the optimal treatment of ventral hernias in patients who present for weight loss surgery. METHODS: Medical records of consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y (LRYGB) gastric bypass with a secondary diagnosis of ventral hernia were reviewed. Only patients who were beyond 6 months of follow-up were included. RESULTS: The study population was 85 patients. There were three groups of patients according to the method of repair: primary repair (59), small intestine submucosa (SIS) (12), and deferred treatment (14). Average follow-up was 26 months. There was a 22% recurrence in the primary repair group. There were no recurrences in the SIS group. Five of the patients in the deferred treatment group (37.5%) presented with small bowel obstruction due to incarceration. CONCLUSION: Biomaterial mesh (SIS) repair of ventral hernias concomitant with LRYGB resulted in the most favorable outcome albeit having short follow-up. Concomitant primary repair is associated with a high rate of recurrence. All incarcerated ventral hernias should be repaired concomitant with LRYGB, as deferment may result in small bowel obstruction.

Variable pulse erbium:YAG laser skin resurfacing of perioral rhytides and side-by-side comparison with carbon dioxide laser.

BACKGROUND AND OBJECTIVE: Laser resurfacing of facial rhytides has become a popular treatment option for many patients with wrinkles, photoaging, and acne scarring. Laser wavelength/pulse duration options and new techniques continue to shorten the healing phase associated with laser skin resurfacing while maintaining clinical efficacy. Variable pulse erbium:YAG (Er:YAG) laser systems are now available that offer the surgeon the ability to vary the Er:YAG pulse duration from a pulse that is primarily ablative to one that is more thermal. The objective of this study was to evaluate the histologic effects created with a variable pulse Er:YAG laser. To study prospectively the clinical effects on upper lip rhytides with a variable pulse Er:YAG laser when compared side by side with pulsed carbon dioxide (CO(2)) laser resurfacing. STUDY DESIGN/MATERIALS AND METHODS: Forty-two treatment sites on 21 patients were randomized and evaluated after treatment of the upper lip region with CO(2) laser resurfacing on one side and a variable pulse Er:YAG laser on the other. Patient diaries were maintained to assess erythema, crusting, pain, and pigmentary changes. Blinded objective grading of improvement was performed. Chromometer measurements were obtained to analyze erythema. RESULTS: The variable pulse Er:YAG laser treatment reduced the duration of crusting on average from 7.7 days with CO(2) to 3.4 days. Chromometer measurements noted decreased postoperative erythema. Grading by physicians in a blinded manner showed 63% improvement for the CO(2) treatment site and 48% improvement in the variable pulse Er:YAG site. No cases of permanent hyperpigmentation, hypopigmentation, or scarring occurred. CONCLUSION: The variable pulse Er:YAG laser resurfacing is a safe and effective resurfacing tool, which combines ablative and thermal modalities. The protocol used in this study approaches but does not equal the results we have traditionally seen with CO(2) laser resurfacing.

Precautions in warming light therapy as an adjuvant to postoperative flap care.

Warming lights, circulating-water blankets, space heaters, and the Bair Hugger are used by surgeons in the perioperative period to maintain a patients core body temperature. Warming lights in particular are often used by plastic surgeons to augment the postoperative vasodilatation of reconstructive flaps by increasing the ambient temperature of the area around the flap. A review of the literature fails to elucidate even anecdotal experience regarding the actual intensity of thermal energy directly imparted to tissues from these modalities with respect to distance. The purpose of our study was to quantify actual tissue temperatures generated, as a function of distance, with the Emerson warming light. Our interest in this is a result of a full-thickness burn which occurred to a portion of a pedicled TRAM flap used for breast reconstruction when a warming light was inadvertently positioned, during the course of the first postoperative night, at a distance less than that recommended by the manufacturer. A biological model was created simulating a sympathectomized flap and the temperature curves generated by Emerson warming lights were recorded by calibrated glass bulb thermometers at 15 min intervals for distances of 32 and 71 cm using both focused and defocused light beams. The distance of 32 cm was used as a parameter as it was the distance noted between the patient and the warming light when the TRAM flap burn occurred. Temperatures obtained at a distance of 32 cm rose to 120 degrees F (48.8 degrees C) within 30 min for the focused beam and 118 degrees F (48 degrees C) after 1 h for the defocused beam. This exceeds the temperature at which tissue necrosis is known to occur (111.2 degrees F/44 degrees C). However, temperatures obtained at 71 cm for the focused and defocused beams plateaued at 93.2 and 96.8 degrees F (34 and 36 degrees C) respectively, which is well within physiologic limits and below the temperature resulting in tissue necrosis. Our conclusion is that warming lights can be successfully used as a safe adjuvant in order to optimize flap vasodilatation without compromising the thermal threshold of tissue damage if maintained at the manufacturer's minimum recommended distance of 71 cm. If this source of thermal energy is used, however, strict precautions and nursing guidelines must be instituted to maintain this minimum distance parameter and prevent patient morbidity.

One-step border molding of complete denture impressions using a polyether impression material.

A technique has been described which uses a polyether impression material for border molding of complete denture impressions. It has the following advantages: 1. There is simultaneous molding of all borders of either the maxillary or mandibular impression. 2. Border molding can be accomplished with one insertion of the tray. 3. Functional movements performed by the patient are used in border molding. 4. The technique is easily mastered.