Corticosteroid response predicts success of laparoscopic splenectomy in treating immune thrombocytopenia.

BACKGROUND: Laparoscopic splenectomy is a second-line therapy for immune thrombocytopenia with a sustained success rate of 66%. In a climate of new available medical therapies for immune thrombocytopenia, the comparative safety and efficacy of laparoscopic splenectomy are worthy of attention. The purpose of this study is to identify factors predictive of laparoscopic splenectomy success that will enable preoperative prognostication. METHODS: A retrospective cohort study was conducted of patients undergoing laparoscopic splenectomy for immune thrombocytopenia. The data collected evaluated response to medical and surgical therapy, which was defined on a platelet level of 50 × 109/L with no bleeding events. Univariate and multivariate analyses were conducted to evaluate factors predictive of laparoscopic splenectomy success, with an additional subanalysis planned to assess for laparoscopic splenectomy safety in individuals ≥65 years. RESULTS: One hundred forty-one patients were reviewed. Operative outcomes showed a 3.6% conversion rate and 8.5% complication rate. Disease remission was achieved in 78.7% of patients. Response to initial corticosteroid therapy was associated with a laparoscopic splenectomy success rate of 90% and increased odds of surgical success by 5.58 over individuals with no response to corticosteroids. Age did not confer an increased risk of failure or complications. CONCLUSION: Laparoscopic splenectomy is a safe and effective intervention for immune thrombocytopenia regardless of age. Initial response to corticosteroids is associated with laparoscopic splenectomy success rate of 90% and improved odds of surgical success. Laparoscopic splenectomy should be the standard second-line therapy for immune thrombocytopenia, especially in patients responding to corticosteroids.

Early Rescue from Acute Severe Clostridium Difficile: A Novel Treatment Strategy.

BACKGROUND: Severe Clostridium difficile infections (CDI) can lead to significant impediments to effective treatment. We developed a novel treatment protocol utilizing bedside gastrointestinal lavage (GIL) for the management of patients with severe, complicated CDI. We describe the development and early outcomes of non-operative bedside GIL in hospitalized patients with severe, complicated CDI following the Idea, Development, Exploration, Assessment, Long Term Study (IDEAL) framework at the Idea stage. We compared our results with those of a cohort of patients managed with colectomy. METHODS: We conducted a retrospective cohort study of hospitalized patients with severe, complicated CDI who failed conventional medical therapy and were referred for surgical consultation at two academic tertiary-care hospitals between January 2009 and January 2015. After surgical assessment, the attending surgeon decided to proceed either with bedside GIL or directly to colectomy. Bedside GIL involved nasojejunal tube insertion followed by flushing with 8 L of polyethylene glycol 3350/electrolyte solution over 48 h. Both patient groups received standard medical treatment with vancomycin 500 mg q 6 h enterally and metronidazole 500 mg intravenously three times daily for 14 d. The main outcomes of interest were the incidence of colectomy, complications, and mortality rate. RESULTS: Nineteen and seventeen patients underwent GIL and direct colectomy, respectively. There were no significant differences between the groups in terms of demographics, American Society of Anesthesiologists class, disease severity, need for intensive care unit admission, mechanical ventilation, vasopressor use, serum lactate concentration, or proportion presenting with hypotension, acute kidney injury, or a white blood cell count >16,000/mcL or <4,000/mcL (p > 0.1). The in-hospital mortality rate was 26% (5/19) and 41% (7/17) for the GIL and colectomy groups, respectively (p = 0.35). Only one patient in the GIL group failed the protocol, requiring colectomy. There were no significant differences in complications in the two groups. CONCLUSIONS: Bedside GIL appeared to be safe for the treatment of patients with severe, complicated CDI who had failed conventional medical therapy. It did not appear to increase the risk of morbidity or death compared with the traditional strategy of proceeding directly to colectomy.

Polyethylene glycol intestinal lavage in addition to usual antibiotic treatment for severe Clostridium difficile colitis: a randomised controlled pilot study.

INTRODUCTION: Clostridium difficile infections (CDI) are common, costly and potentially life threatening. Most CDI will respond to antibiotic therapy, but 3%-10% of all patients with CDI will progress to a severe, life-threatening course. Complete removal of the large bowel is indicated for severe CDI. However, the 30-day mortality following surgical intervention for severe CDI ranges from 20% to 70%. A less invasive approach using surgical faecal diversion and direct colonic lavage with polyethylene glycol (PEG) and vancomycin has demonstrated a relative mortality reduction of approximately 50%. As an alternative to these operative approaches, we propose to treat patients with bedside intestinal lavage with PEG and vancomycin instillation via nasojejunal tube, in addition to usual antibiotic management. Preliminary data collected by our research group are encouraging. METHODS AND ANALYSIS: We will conduct a 1-year, single-centre, pilot randomised controlled trial to study this new treatment strategy for patients with severe CDI and additional risk factors for fulminant or complicated infection. After informed consent, patients with severe-complicated CDI without immediate indication for surgery will be randomised to either usual antibiotic treatment or usual antibiotic treatment with the addition of 8 L of PEG lavage via nasojejunal tube. This pilot trial will evaluate our eligibility and enrolment rate, protocol compliance and adverse event rates and provide further data to inform a more robust sample size calculation and protocol modifications for a definitive multicentre trial design. Based on historical data, we anticipate enrolling approximately 24 patients during the 1-year pilot study period.As a pilot study, data will be reported in aggregate. Between-group differences will be assessed in a blinded fashion for evidence of harm, and to further refine our sample size calculation. ETHICS AND DISSEMINATION: This study protocol has been reviewed and approved by our local institutional review board. Results of the pilot trial and subsequent main trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT02466698; Pre-results.

Local and national laparoscopic skill competitions: residents' opinions and impact on adoption of simulation-based training.

BACKGROUND: Dedicated practice using laparoscopic simulators improves operative performance. Yet, voluntary utilization is minimal. We hypothesized that skill competition between peers, at the local and national level, positively influences residents' use of laparoscopic simulators. METHODS: A web-based survey evaluated the relationship between Canadian General Surgery residents' use of laparoscopic simulation and participation in competition. Secondary outcomes assessed attitudes regarding simulation training, factors limiting use, and associations between competition level and usage. RESULTS: One hundred ninety (23%) of 826 potential participants responded. Eighty-three percent rated their laparoscopic abilities as novice or intermediate. More than 70% agreed that use of simulation practice improves intra-operative performance, and should be a mandatory component of training. However, 58% employed simulator practice less than once per month, and 18% never used a simulator. Sixty-five percent engaged in simulator training for 5 h or less over the preceding 6 months. Seventy-three percent had participated in laparoscopic skill competition. Of those, 51% agreed that competition was a motivation for simulation practice. No association was found between those with competition experience and simulator use. However, 83% of those who had competed nationally reported >5 h of simulator use in the previous 6 months compared to those with no competition experience (26%), local competition (40%), and local national-qualifying competition (23%) (p < 0.001). CONCLUSIONS: This study does not support the hypothesis that competition alone universally increases voluntary use of simulation-based training, with only the minority of individuals competing at the national level demonstrated significantly higher simulation use. However, simulation training was perceived as a valuable exercise. Lack of time and access to simulators, as opposed to lack of interest, were the most commonly reported to limited use.

A serious game skills competition increases voluntary usage and proficiency of a virtual reality laparoscopic simulator during first-year surgical residents' simulation curriculum.

BACKGROUND: The objective of this study was to assess the effect of a serious game skills competition on voluntary usage of a laparoscopic simulator among first-year surgical residents' standard simulation curriculum. METHODS: With research ethics board approval, informed consent was obtained from first-year surgical residents enrolled in an introductory surgical simulation curriculum. The class of 2013 served as a control cohort following the standard curriculum which mandates completion of six laparoscopic simulator skill tasks. For the 2014 competition cohort, the only change introduced was the biweekly and monthly posting of a leader board of the top three and ten fastest peg transfer times. Entry surveys were administered assessing attitudes towards simulation-based training and competition. Cohorts were observed for 5 months. RESULTS: There were 24 and 25 residents in the control and competition cohorts, respectively. The competition cohort overwhelmingly (76 %) stated that they were not motivated to deliberate practice by competition. Median total simulator usage time was 132 min (IQR = 214) in the competition cohort compared to 89 (IQR = 170) in the control cohort. The competition cohort completed their course requirements significantly earlier than the control cohort (χ 2 = 6.5, p = 0.01). There was a significantly greater proportion of residents continuing to use the simulator voluntarily after completing their course requirements in the competition cohort (44 vs. 4 %; p = 0.002). Residents in the competition cohort were significantly faster at peg transfer (194 ± 66 vs. 233 ± 53 s, 95 % CI of difference = 4-74 s; p = 0.03) and significantly decreased their completion time by 33 ± 54 s (95 % CI 10-56 s; paired t test, p = 0.007). CONCLUSIONS: A simple serious games skills competition increased voluntary usage and performance on a laparoscopic simulator, despite a majority of participants reporting they were not motivated by competition. Future directions should endeavour to examine other serious gaming modalities to further engage trainees in simulated skills development.