Effect of the 16-hour work limit on general surgery intern operative case volume: a multi-institutional study.

IMPORTANCE: The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction. OBJECTIVE: To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience. DESIGN, SETTING, AND PARTICIPANTS: A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included. MAIN OUTCOMES AND MEASURES: Total, major, first-assistant, and defined-category case totals. RESULTS: As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases. CONCLUSIONS AND RELEVANCE: The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

Predicting performance on the American Board of Surgery qualifying and certifying examinations: a multi-institutional study.

BACKGROUND: We sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents. DESIGN: Retrospective review. SETTING: Seventeen general surgery training programs in the western United States. PARTICIPANTS: Six hundred seven residents who graduated in 2000-2007. MAIN OUTCOME MEASURES: First-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research. RESULTS: The first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]). CONCLUSIONS: Residents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Video. Magnetic retraction for NOTES transvaginal cholecystectomy.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has the potential to decrease the burden of an operation on a patient. Limitations of the endoscopic platform require innovative solutions to provide retraction and create an operation comparable with the gold standard, laparoscopic cholecystectomy. METHODS: Four patients underwent transvaginal cholecystectomy. All procedures were performed under laparoscopic vision to ensure safety. The endoscope and a long articulating RealHand instrument were placed via a 15-mm vaginal trocar. A magnetic retraction system was used to retract the gallbladder safely. Laparoscopic clips were used to ligate the cystic duct and artery. All four gallbladders were successfully removed. No complications occurred. The mean operating time was 102 min. RESULTS: All four procedures were completed without complications. The four patients all were discharged shortly after surgery and reported normal sexual activity without pain. CONCLUSIONS: Transvaginal cholecystectomy can be completed safely using current technology. Further studies are needed to determine the safety of the procedure and to determine whether it confers any benefits other than cosmesis.

The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures.

BACKGROUND: During transgastric natural orifice transluminal endoscopic surgery (NOTES), there is an iatrogenic perforation of the gastric wall with leakage of gastric contents into the peritoneal cavity. The aim of this study is to determine the effect of proton-pump inhibitors (PPI) and alterations of gastric pH on infection during transgastric surgery. METHODS: Thirty 250-g male Sprague-Dawley rats were divided into a study group (SG, n = 15) and a control group (CG, n =15). SG were given 5 mg/kg pantoprazole for 3 days before procedure and another dose 1 h before. CG received saline at similar time points. A mini-laparotomy with gastrotomy was performed. Aspiration of 2.0 cc gastric contents was removed from the stomach and injected into the peritoneal cavity of both groups. Gastric pH and peritoneal pH levels were obtained. Gastric aspirate was sent for culture. White blood cell counts (WBC) were obtained on postoperative days 1, 7, and 14, and C-reactive protein (CRP) levels were obtained on postoperative day 1. At day 14, a necropsy was performed and aerobic and anaerobic cultures of the peritoneal cavity were obtained. RESULTS: There were no deaths in either group. The average gastric pH in the SG was 5.13 versus 3.26 (p = 0.03) in the CG. The average peritoneal pH was similar in both groups. The WBC in the SG was 4.5 vs. 3.5 (1,000 cells/mm) in the CG. There was no elevation in CRP levels in either group. Bacterial cultures were positive in 3/15 (20%) rats in the CG and in 9/15 (60%) in the SG (p = 0.008). Intra-abdominal abscesses were found in 2/15 (13%) rats in the CG and in 5/15 (33%) in the SG (p = 0.08). CONCLUSIONS: Pretreatment with a PPI resulted in a higher rate of peritoneal bacterial contamination and abscess formation. The acidic environment of the stomach appears to be protective against infection when intraperitoneal contamination occurs as a result of gastrotomy.

The inflammatory response in transgastric surgery: gastric content leak leads to localized inflammatory response and higher adhesive disease.

BACKGROUND: Risk of gastric spillage during transgastric surgery is a potential complication of NOTES procedures. The aim of this study was to determine risk outcomes from gastric spillage in a rat survival model by measuring local and systemic inflammatory markers, adhesive disease, and morbidity. METHODS: We performed a minilaparotomy with needle aspiration of 2 ml of gastric contents mixed with 2 ml of sterile saline (study group, SG) or 4 ml of sterile saline (control group, CG) injected into the peritoneal cavity of 60 male rats. Inflammatory markers (TNFalpha, IL-6, and IL-10) were analyzed at 1, 3, 6, and 24 h postoperatively by obtaining plasma levels and peritoneal washings. At necropsy, the peritoneal cavity was examined grossly for adhesions. RESULTS: Adhesions were seen more frequently in the SG versus the CG (100% vs. 33.3%, p < 0.014). There was a significant difference in the peritoneal TNFalpha levels in the SG compared with the CG, which peaked 1 h after surgery (p < 0.02). Both peritoneal IL-6 and IL-10 levels were higher in the SG versus the CG, which peaked 3 h after surgery (p < 0.005 and p < 0.001, respectively). All peritoneal inflammatory markers returned to undetectable levels at 24 h for both groups. Plasma cytokines were undetectable at all time intervals. CONCLUSION: The inflammatory response was found to be a localized and not systemic event, with plasma cytokine levels remaining normal while peritoneal washings revealed a brisk, short-lived localized inflammatory response. There was a significantly higher rate of adhesive disease in the SG compared with the CG; this, however did not translate into a difference in apparent clinical outcome. We conclude that gastric leakage in this NOTES rodent model induces a localized inflammatory response, followed by mild to moderate adhesive disease. This may be important in human NOTES.

Video. NOTES: transvaginal cholecystectomy with assisting articulating instruments.

BACKGROUND: Transvaginal cholecystectomy has been performed at several institutions using hybrid natural orifice translumenal endoscopic surgery (NOTES) techniques. METHODS: A 42-year-old woman with symptomatic cholelithiasis was taken to the operating room for transvaginal cholecystectomy after giving informed consent. A single 5-mm laparoscope was placed at the umbilicus, followed by a 15-mm trocar through the vaginal conduit. The endoscope and a long flexible RealHand surgical instrument (Novare, Cupertino, CA) were placed via the vaginal trocar. The cystic duct and artery were identified and clipped using laparoscopic clips from the umbilical port. The long articulating laparoscopic instrument provided stable retraction. Hook cautery was used to dissect the gallbladder, which was removed via the vaginal trocar. The vaginal incision was closed using a single figure-of-eight absorbable suture under direct vision. The procedure lasted 96 min. RESULTS: The cholecystectomy was successfully performed without spillage of bile. The patient was kept overnight for observation only as a precaution. She reported no pain and did not require a discharge prescription for narcotics. CONCLUSIONS: The described technique for NOTES cholecystectomy results in a virtually scarless operation. The single 5-mm umbilical trocar allows for safe clipping of the cystic duct. Further work is needed to determine the efficacy of this approach.

Natural orifice surgery: initial clinical experience.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) has moved quickly from preclinical investigation to clinical implementation. However, several major technical problems limit clinical NOTES including safe access, retraction and dissection of the gallbladder, and clipping of key structures. This study aimed to identify challenges and develop solutions for NOTES during the initial clinical experience. METHODS: Under an Institutional Review Board (IRB)-approved protocol, patients consented to a natural orifice operation for removal of either the gallbladder or the appendix via either the vagina or the stomach using a single umbilical trocar for safety and assistance. RESULTS: Nine transvaginal cholecystectomies, one transgastric appendectomy, and one transvaginal appendectomy have been completed to date. All but one patient were discharged on postoperative day 1 as per protocol. No complications occurred. CONCLUSION: The limited initial evidence from this study demonstrates that NOTES is feasible and safe. The addition of an umbilical trocar is a bridge allowing safe performance of NOTES procedures until better instruments become available. The addition of a flexible long grasper through the vagina and a flexible operating platform through the stomach has enabled the performance of NOTES in a safe and easily reproducible manner. The use of a uterine manipulator has facilitated visualization of the cul de sac in women with a uterus to allow for safe transvaginal access.

Hybrid natural orifice translumenal surgery (NOTES) sleeve gastrectomy: a feasibility study using an animal model.

BACKGROUND: The indications for natural orifice translumenal surgery (NOTES) are yet to be determined. Morbidly obese patients may be one population that would benefit from this approach due to the elimination of wound complications and possibly a faster recovery. As a bariatric restrictive procedure, sleeve gastrectomy could be one indication for NOTES. To test the feasibility of this procedure with a NOTES approach, a pig model was used. METHODS: Acute studies investigated five 40-kg farm pigs. The rectum was used as the port of entry to the peritoneal cavity, and the stomach was manipulated endoluminally using a gastroscope. Vision was acquired through a 5-mm laparoscope introduced transabdominally (i.e. via the hybrid technique). A 10-mm incision was made on the anterior wall of the rectum and dilated to accommodate a 12-mm trocar introduced through the rectal wall into the peritoneal cavity. The greater curvature of the stomach then was divided and detached, starting from the antrum and proceeding to the esophagogastric junction using a laparoscopic stapler. The sleeve gastrectomy was completed by dividing the short gastric vessels with an ultrasonic scalpel. The gastric pouch then was removed through the rectal incision. RESULTS: A NOTES gastric sleeve resection was successfully performed in all five pigs. The technique was developed, and feasibility was determined. After resection, the gastric remnant was inflated, with no evidence of leakage. At autopsy, intact suture lines were noted. Closure of the rectal incision was not attempted. CONCLUSION: A NOTES sleeve gastrectomy is feasible in porcine animal models. The rectal port of entry allows rigid laparoscopic instruments to be introduced into the peritoneal cavity and enables performance of gastrointestinal procedures the same as in standard laparoscopic surgery. Extra-long instruments are necessary for dissection and division of the stomach at the esophagogastric junction and for accessing the short gastric vessels.

A Monte Carlo study of isomers and structural evolution in benzene-cyclohexane clusters: (C6H6)(C6H12)n, n=3-7, 12.

Monte Carlo simulated annealing strategies, carried out on four different potential energy surfaces, are applied to benzene-cyclohexane clusters, BCn, n=3-7, 12, to identify low-energy isomers and to trace the evolution of structures as a function of cluster size. Initial structures are first heated to ensure randomization, and subsequent annealing yields optimized rigid, low-energy clusters. Five major structural isomers are identified for BC3: one assumes the form of a symmetric, modified sandwich; the remaining four lack general symmetry, assuming distorted tetrahedral arrangements. For BC4 and larger clusters, the number of low-temperature isomers is large. It is, nevertheless, feasible to classify isomers into groups based on structural similarities. The evolution of BCn structures as a function of cluster size is observed to follow one of two primary paths: The first maximizes benzene-cyclohexane interactions and places benzene in or near the BCn cluster center; the competing path maximizes cyclohexane-cyclohexane interactions and distances benzene from the cluster's center of mass. Results for BC3 and BC4 are discussed with reference to experimental results and models previously applied to interpret benzene-argon cluster spectra.

NOTES: the hybrid technique.

INTRODUCTION: Natural orifice translumenal endoscopic surgery (NOTES) has gained much interest by minimal invasive surgeons and gastroenterologists. Performing abdominal operations without any abdominal wall incisions may offer all the advantages of minimally invasive surgery (MIS) and eliminate the complications associated with these wounds. The NOTES technique is rapidly being developed, but one of the major issues involved in the procedure that has to be addressed prior to implementation is in obtaining adequate spatial orientation. OBJECTIVE: The aim of this study was to combine the standard laparoscopic vision together with the endoscopic surgery procedure in order to acquire an independent satisfactory vision source. MATERIALS AND METHODS: The hybrid technique was performed in 6 porcine animal models. Among the procedures performed were tubal ligation, liver biopsies, oophorectomy, and cholecystectomy. All procedures were performed under general anesthesia, and all animals were euthanized at the termination of the procedure. RESULTS: The laparoscopic vision offers substantial advantages over the endoscopic vision. Spatial orientation is achieved in the same manner and quality as in MIS, and furthermore, the laparoscopic vision increases the safety of the NOTES procedure. CONCLUSIONS: The hybrid technique offers a superior vision source independent to the working endoscope. It may be an interim technique for developing NOTES until a novel imaging device will be available, or serve as the final solution for acquiring an adequate vision for this approach.

Minimally invasive procedures for diagnosis of traumatic right diaphragmatic tears: a method for correct diagnosis in selected patients.

Traumatic rupture of the diaphragm is no longer uncommon. Because of the increasing frequency of motor vehicle accidents, the rate of blunt trauma to the chest and abdomen, which are the most common causes of diaphragmatic rupture, is increased as well. However, the diagnosis is frequently missed or delayed because of the lack of sensitivity and specificity of imaging modalities. Diagnostic laparoscopy is considered a standard tool for penetrating injuries to the left diaphragm and is widely practiced in selected cases. Right diaphragmatic tears, however, are more difficult to diagnose because of the sealing effect of the liver. Blunt abdominal trauma can cause large right diaphragmatic tears, causing liver incarcerations and respiratory compromise, therefore demanding the need for a comparable diagnostic tool. A high index of suspicion, together with knowledge of the mechanism of trauma, is the key factor for the correct diagnosis. Once the diagnosis has been considered, diagnostic laparoscopy and/or diagnostic thoracoscopy should be performed to confirm or rule out this injury. Factors suggestive of a right diaphragmatic tear include newly or progressive elevation of the right diaphragm and respiratory distress without underlining lung injury. The timing of the procedure should be in accordance with the hemodynamic and respiratory status of the patient. This procedure should be performed semielectively if there are no other indications for surgical intervention.

Monte Carlo studies of isomers, structures, and properties in benzene-cyclohexane clusters: computation strategy and application to the dimer and trimer, (C6H6)(C6H12)n, n = 1-2.

Low-temperature isomeric energies, structures, and properties of benzene-cyclohexane clusters are investigated via Monte Carlo simulations. The Monte Carlo strategy is first documented and then applied to (C(6)H(6))(C(6)H(12)) and (C(6)H(6))(C(6)H(12))(2) using four different potential energy surfaces. Results identify a single parallel-displaced dimer isomer. MP2 optimizations and frequency calculations support the Monte Carlo dimer structure and identify the van der Waals mode observed in vibronic spectra. Caloric simulations identify two temperatures where structural transitions occur and imply an experimental temperature below 10 K for dimers in cold supersonic expansions. The (C(6)H(6))(C(6)H(12))(2) studies identify eight independent trimer isomers: three form parallel-stacked (sandwich) arrangements with the two cyclohexane moieties related through a D(6)(h) transformation. The remaining five trimer isomers are trigonal, with no overall symmetry. Caloric studies indicate that the sandwich and trigonal isomeric classes coexist independently below 60 K, consistent with trimer vibronic spectra that contain two independent van der Waals progressions.

Disclosing and responding to cancer "fears" during oncology interviews.

Video-excerpts from routine oncology interviews are examined to reveal how patients demonstrate and doctors respond to "fears" about cancer. Vocally and visually, embodied impacts of dealing with dreaded consequences of cancer are apparent when addressing both good and potentially bad cancer news. Even a "brush" with cancer can promote negative and ongoing impacts provoking unresolved illness dilemmas. We reveal how, in the midst of extending answers and initiating concerns, patients exhibit trepidations when volunteering narrative information about their medical history and experience of symptoms. In response, doctors are shown to acknowledge yet exhibit minimal receptiveness to patients' lifeworld disclosures and demonstrations (e.g., redirecting attention away from patients' concerns by offering "textbook" symptoms and related pursuits of biomedical agendas). Discussion focuses on interactional criteria for identifying "fears", patients' lay orientations to medical visits, and implications for refining educational workshops for oncologists.

Competent patient care is dependent upon attending to empathic opportunities presented during interview sessions.

OBJECTIVE: Core competencies in surgical education and clinical care rely on effective patient-physician communication. We aim to develop quantitative and empirical tools for understanding critical communication tasks during patient interviews. METHODS: Residents in surgical training and attending physicians were separately video recorded during stressful, first visit oncology patient interview sessions. Taped sessions (n = 16) were analyzed in detail to identify and label patient-initiated actions (PIAs), or "empathic opportunities," that call for recognition or action from the caregiver. Doctor-responsive actions (DRAs) were labeled as matching to, or missing from, each empathic opportunity. Missed empathic opportunities occurred when a PIA did not have an associated DRA. Presession and postsession surveys queried the patient's perception of how well their health-care needs were met. RESULTS: Resident trainees and attending physicians missed 70% of 160 clearly identified empathic opportunities. There was no clear association with the level of physician training. This pilot study did not have enough power to discern differences in patient satisfaction. CONCLUSIONS: Physicians are often not very attentive to empathic opportunities offered by patients. Individual feedback and training regarding empathic opportunities in recorded patient communication encounters may improve resident and physician core competencies. These improvements may affect patient satisfaction related to these encounters.

Simultaneous serous cystadenoma of the pancreas and mucinous cystadenoma of the appendix.

CONTEXT: Serous cystadenoma of the pancreas and mucinous tumors of the vermiform appendix are rare. To our knowledge, the simultaneous occurrence of these two tumors has not been reported. CASE REPORT: Here, we report an adult female who presented with signs and symptoms of appendicitis. A preoperative CT scan confirmed the findings of appendicitis and also showed an incidental large mass in the head of the pancreas. The patient underwent uneventful appendectomy. Her pathology revealed an acutely inflamed appendix with a benign mucinous cystadenoma at the tip. Several months after her recovery, a Whipple procedure was performed. Pathologic examination showed a 5x5 cm serous cystadenoma of the head of the pancreas without evidence of malignancy. Two years later, the patient is alive and well without evidence of tumor recurrence. CONCLUSIONS: Cystadenomas of the pancreas and appendix are unusual and their simultaneous occurrence is a rare event.