Evaluation of training and professional expectations of surgery residents.

Residency programs, especially in surgery, have been undergoing constant changes, not only in our country, but also internationally. Due to the depreciation of medical specialties and their lowering compensation, expectations and profile of residents in surgical fields are changing. The assessment of attitudes, experience in training and professional expectations among residents is an important topic. Recent international studies published in the area demonstrate this fact. It is worth noting the absence of similar studies in our country, as well as others. This study aims to assess the residents of the area of surgery, through a questionnaire, their attitudes, experiences during training and professional expectations. We applied and analyzed questionnaires adapted and translated into Portuguese to 50 professionals of both sexes and different years of residence. The results of this study showed high satisfaction with the specialty, but large financial concern and conflicting opinions about the future of the specialty.

Avaliação do treinamento e expectativas profissionais em residentes de cirurgia / Evaluation of trainning and professional expectations of surgery residents

Os programas de residência médica, em especial na cirurgia, vêm passando por modificações constantes, não só em nosso meio, como internacionalmente. Em virtude da deterioração da valorização e remuneração médica, as expectativas e perfil do médico residente na área cirúrgica vêm mudando. A avaliação das atitudes, experiência durante o treinamento e expectativas profissionais nos residentes é tópico importante. Recentes trabalhos internacionais publicados na área demonstram tal fato. É digno de nota a ausência de trabalhos semelhantes em nosso meio e a raridade em outros países. O presente estudo tem por objetivo avaliar em médicos residentes da área de cirurgia, através de questionário, atitudes, experiências durante o treinamento e expectativas profissionais. Foram aplicados e analisados questionários adaptados e traduzidos para o Português em 50 residentes de ambos os sexos e diferentes anos de residência. Os resultados deste trabalho mostram alta satisfação com a especialidade, porém grande preocupação financeira e opiniões conflitantes quanto ao futuro da especiliadade;.

Residency programs, especially in surgery, have been undergoing constant changes, not only in our country, but also internationally. Due to the depreciation of medical specialties and their lowering compensation, expectations and profile of residents in surgical fields are changing. The assessment of attitudes, experience in training and professional expectations among residents is an important topic. Recent international studies published in the area demonstrate this fact. It is worth noting the absence of similar studies in our country, as well as others. This study aims to assess the residents of the area of surgery, through a questionnaire, their attitudes, experiences during training and professional expectations. We applied and analyzed questionnaires adapted and translated into Portuguese to 50 professionals of both sexes and different years of residence. The results of this study showed high satisfaction with the specialty, but large financial concern and conflicting opinions about the future of the specialty.

Hiatal mesh repair--current status.

Most surgeons believe that cruroplasty (hiatoplasty) is an essential part of antireflux operations. One of the main causes of failure after antireflux operation is gastric (wrap) herniation through the hiatus that may be attributed to breakdown of the hiatal closure or a faulty repair. Surgeons are at present faced with the dilemma of choosing between a risk of recurrence and the fear of complications of prosthetic hiatal reinforcement. We reviewed the literature to evaluate the current status of hiatal mesh repair (HMR). Indication, technique, complications, and results are shown. Available data show a small number of mesh-related complications compared with the number of patients submitted to the procedure, and better results of HMR compared with simple hiatal closure. We support the use of HMR when performed by skilled foregut surgeons, as complications described occurred more frequently in the earliest cases of the series. In addition, HMR should be probably used selectively. However, studies to identify the patients at risk of hernia recurrence or mesh-related complications are still elusive. The ideal type of mesh and the ideal technique for mesh implantation are yet to be established.

Postprandial proximal gastric acid pocket in patients after laparoscopic Nissen fundoplication.

BACKGROUND: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether change in the PPGAP may contribute to GERD control. This study aims to analyze the presence of PPGAP in patients submitted to Nissen fundoplication. METHODS: Fifteen patients who had a laparoscopic Nissen fundoplication (mean age = 61 years, 13 females, mean time from operation 1 year) were studied. All patients were free of foregut symptoms. Patients underwent high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES).Station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. RESULTS: Four patterns of gastric acidity were found: (1) acid was not detected in the studied area of the stomach in 8 (53%) patients; (2) constant acidity (stomach is not alkalinized after meal), i.e., a buffered layer was not found in 3 (20%) patients; (3) PPGAP was not detected, i.e., the whole stomach is alkalinized, in 1 (7%) patient; and (4) PPGAP was noted in 3 (20%) patients with extensions of 2, 2, and 5 cm. CONCLUSION: PPGAP is present in a minority of patients after Nissen fundoplication. This finding may explain part of the GERD control and that the gastric fundus may play a role in the genesis of the PPGAP.

Postprandial proximal gastric acid pocket in patients after Roux-en-Y gastric bypass.

INTRODUCTION: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in normal individuals and patients with gastroesophageal reflux disease (GERD). The role of gastric anatomy in the physiology of the PPGAP remains unclear. It is also unclear whether operations that control GERD, such as Roux-en-Y gastric bypass (RYGB) and Nissen fundoplication, change the PPGAP. AIMS: This study aims to analyze the presence of PPGAP in patients submitted to RYGB. METHODS: Fifteen patients who had a RYGB for morbid obesity (mean age 53 years, 14 females, mean time from operation 3 years) were studied. All patients were free of foregut symptoms. Patients underwent a high-resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES). A station pull-through pH monitoring was performed from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal (40 g of chocolate, 50% fat). RESULTS: Acidity was not detected in the stomach of four patients before meal. After meal, PPGAP was not found in eight patients. In three patients, a PPGAP was noted with an extension of 1 to 3 cm. CONCLUSION: PPGAP is present in a minority of patients after RYGB; this finding may explain part of the GERD control after RYGB and that the gastric fundus may play a role in the genesis of the PPGAP.

Duodenal bypass does not decrease glucose levels of lean individuals with gastric cancer submitted to partial or total gastrectomy.

Change in glucose metabolism after bariatric operations may be credited to duodenal bypass. This study aims to evaluate the effect of duodenal bypass on glucose levels in lean individuals submitted to gastrectomy for gastric cancer. We reviewed 56 non-diabetic and 6 diabetic patients submitted to gastrectomy and Roux-en-Y for gastric cancer (partial gastrectomy in 66%/total gastrectomy in 34%). Glucose levels were not significantly altered after operation (P = 0.5). Diabetes control was improved in one patient with oral medication. In conclusion, duodenal bypass do not decrease glucose levels in lean individuals treated for gastric cancer.

Duodenal bypass does not decrease glucose levels of lean individuals with gastric cancer submitted to partial or total gastrectomy / O desvio do duodeno não diminui os níveis glicêmicos em indivíduos magros com câncer gástrico submetidos a gastrectomia parcial ou total

Change in glucose metabolism after bariatric operations may be credited to duodenal bypass. This study aims to evaluate the effect of duodenal bypass on glucose levels in lean individuals submitted to gastrectomy for gastric cancer. We reviewed 56 non-diabetic and 6 diabetic patients submitted to gastrectomy and Roux-en-Y for gastric cancer (partial gastrectomy in 66 percent/total gastrectomy in 34 percent). Glucose levels were not significantly altered after operation (P = 0.5). Diabetes control was improved in one patient with oral medication. In conclusion, duodenal bypass do not decrease glucose levels in lean individuals treated for gastric cancer.

Alterações no metabolismo da glucose após cirúrgias bariátricas podem ser creditadas ao desvio do duodeno. Este estudo avaliou o efeito do desvio do duodeno nos níveis glicêmicos de pacientes magros submetidos a gastrectomia por câncer. Foram revistos 56 pacientes não-diabéticos e 6 pacientes diabéticos submetidos a gastrectomia com reconstrução em Y-de-Roux por câncer (gastrectomia parcial em 66 por cento e total em 34 por cento). Os níveis glicêmicos não se alteraram significantemente depois da operação (P = 0,5). Houve melhora do diabetes em um paciente com medicação oral. Em conclusão, o desvio duodenal não diminui os níveis glicêmicos de indivíduos magros tratados por câncer gástrico.

Gastrectomy and lymphadenectomy for gastric cancer: is the pancreas safe?

INTRODUCTION: Resection of the capsule of the pancreas is part of the radical operation proposed by oriental authors for the treatment of gastric cancer. It is unclear; however, if resection of the capsule is a safe procedure or even if it is necessary. This study aims to assess in patients treated for gastric cancer the occurrence of: (a) pancreatic fistula and (b) metastasis to the pancreatic capsule. METHODS: We studied 80 patients (mean age 61 years, 42 males) submitted to gastrectomy with resection of the pancreatic capsule by hydrodissection. Patients with pancreatic disease, tumoral invasion of the pancreas, submitted to concomitant splenectomy, or anastomotic leakage were excluded. The tumor was located in the distal third of the stomach in 60% of the patients, in the middle third in 27%, and proximally in 12%. Total gastrectomy was performed in 27% of the cases and partial gastrectomy in 73%. In all patients, amylase activity in the drainage fluid was measured on day 2. If initial measurement was abnormal, subsequent measurements were performed in alternated days until normalization. Pancreatic fistula was defined as amylase levels greater than 600. In 25 of these patients (mean age 53 years, 16 males), the pancreatic capsule was histologically analyzed for metastasis. RESULTS: Pancreatic fistula was diagnosed in eight (10%) patients. The mean amylase level was 5,863. Normalization of amylase levels was achieved within 7 days in all patients. No patient developed clinical signs of fistula besides abnormal amylase levels in the drainage fluid, such as intra-abdominal abscesses. Pancreatic fistula was associated to younger age (p = 0.03) but not to gender (p = 0.1), tumor location (p = 0.6), and type of gastrectomy (p = 0.8). Metastasis to the pancreatic capsule was not identified. CONCLUSION: In conclusion, resection of the pancreatic capsule must be discouraged due to subclinical pancreatic fistula in a significant number of the cases and absence of metastasis.

Surgical treatment of primary esophageal motility disorders.

Named primary esophageal motility disorders (PEMD) present with specific manometric patterns classified as: (1) hypertensive lower esophageal sphincter, (2) nutcracker esophagus (also hypercontratile, hypertensive, or hypercontracting esophagus), (3) diffuse esophageal spasm, and (4) achalasia. These conditions, with the exception of achalasia, are rare, poorly understood, and inadequately studied. Treatment of these conditions is based on symptoms and aimed at symptomatic improvement. The authors reviewed current literature on surgical treatment of non-achalasia PEMD. The review shows that: (a) surgical therapy may be an attractive alternative in patients with PEMD; (b) proper selection of patients based on symptoms evaluation and esophageal function tests is essential; (c) laparoscopic myotomy with proximal extent tailored to manometric findings seems to be the ideal surgical therapy; and (d) esophagectomy may be necessary as a last resource due to multiple failures of surgical conservative treatment.

Are idiopathic and Chagasic achalasia two different diseases?

Although Chagas' disease esophagopaty and idiopathic (primary) achalasia share several similarities, however, some differences between the two diseases have been noticed. To evaluate if treatment options and their results can be accepted universally, the authors review characteristics of both diseases in the international and Latin American literature. Neuronal denervation, sensitivity to gastrin, patient age, duration of symptoms, lower esophageal sphincter pressure, incidence of vigorous achalasia, and cancer risk are considered points of discrepancy between the maladies. Data with a high level of evidence base are scarce; however, differences between the diseases seem to exist, despite the fact that no influence on response to treatment was noticed.