Postoperative Recovery in Frail, Pre-frail, and Non-frail Elderly Patients Following Abdominal Surgery.

BACKGROUND: The objective of this study is to explore the association between frailty and surgical recovery over a 6-month period, in elderly patients undergoing elective abdominal surgery. METHODS: A total of 144 patients were categorized as frail, pre-frail, and non-frail based on five criteria: weight loss, exhaustion, weakness, slowness, and low activity. Recovery to preoperative functional status (activities of daily living (ADL) and instrumental activities of daily living (IADL)), cognition, quality of life, and mental health was assessed at 1, 3, and 6 months postoperatively. A repeated measure logistic regression was used to analyze the effect of frailty on recovery over time. The effect of frailty on hospitalization outcomes was also evaluated. RESULTS: Mean age was 78 ± 5 years with 17.4% of patients categorized as frail, 60.4% pre-frail, and 22.2% non-frail. At 6 months, the percent of patients who had recovered to preoperative values were: ADL 90%; IADL 76%; cognition 75.5%; mental health 66%; and quality of life 70%. While more frail patients experienced adverse hospitalization outcomes and fewer had recovered to preoperative functional status, these differences were not found to be statistically significant. Overall, frailty status was not significantly associated with the trajectory of recovery or hospitalization outcomes. CONCLUSION: Strong, institutional commitment to quality surgical care, as well as appropriate strategies for older patients, may have mitigated the impact of frailty on recovery. Further research is needed to examine the role of frailty in the surgical recovery process.

Assessing the Effect of Preoperative Nutrition on Upper Body Function in Elderly Patients Undergoing Elective Abdominal Surgery.

BACKGROUND: Malnutrition among elderly surgical patients has been associated with poor postoperative outcomes and reduced functional status. Although previous studies have shown that nutrition contributes to patient outcomes, its long-term impact on functional status requires better characterization. This study examines the effect of nutrition on postoperative upper body function over time in elderly patients undergoing elective surgery. METHODS: This is a 2-year prospective study of elderly patients (≥70 years) undergoing elective abdominal surgery. Preoperative nutrition status was determined with the Subjective Global Assessment (SGA). The primary outcome was handgrip strength (HGS) at 1, 4, 12, and 24 weeks postsurgery. Repeated measures analysis was used to determine whether SGA status affects the trajectory of postoperative HGS. RESULTS: The cohort included 144 patients with a mean age of 77.8 ± 5.0 years and a mean body mass index of 27.7 ± 5.1 kg/m2 . The median (interquartile range) Charlson Comorbidity Index was 3 (2-6). Participants were categorized as well-nourished (86%) and mildly to moderately malnourished (14%), with mean preoperative HGS of 25.8 ± 9.2 kg and 19.6 ± 7.0 kg, respectively. At 24 weeks, 64% of well-nourished patients had recovered to baseline HGS, compared with 44% of mildly to moderately malnourished patients. Controlling for relevant covariates, SGA did not significantly affect the trajectory of postoperative HGS. CONCLUSION: While HGS values over the 24 weeks were consistently higher in the well-nourished SGA group than the mildly to moderately malnourished SGA group, no difference in the trajectories of HGS was detected between the groups.

Virtual reality robotic surgery simulation curriculum to teach robotic suturing: a randomized controlled trial.

The objective of this randomized, controlled trial was to assess whether voluntary participation in a proctored, proficiency-based, virtual reality robotic suturing curriculum using the da Vinci(®) Skills Simulator™ improves robotic suturing performance. Residents and attending surgeons were randomized to participation or non-participation during a 5 week training curriculum. Robotic suturing skills were evaluated before and after training using an inanimate vaginal cuff model, which participants sutured for 10 min using the da Vinci(®) Surgical System. Performances were videotaped, anonymized, and subsequently graded independently by three robotic surgeons. 27 participants were randomized. 23 of the 27 completed both the pre- and post-test, 13 in the training group and 10 in the control group. Mean training time in the intervention group was 238 ± 136 min (SD) over the 5 weeks. The primary outcome (improvement in GOALS+ score) and the secondary outcomes (improvement in GEARS, total knots, satisfactory knots, and the virtual reality suture sponge 1 task) were significantly greater in the training group than the control group in unadjusted analysis. After adjusting for lower baseline scores in the training group, improvement in the suture sponge 1 task remained significantly greater in the training group and a trend was demonstrated to greater improvement in the training group for the GOALS+ score, GEARS score, total knots, and satisfactory knots.

Recurrence of biliary disease following non-operative management in elderly patients.

INTRODUCTION: The purpose of this study was to determine the proportion of symptomatic recurrence following initial non-operative management of gallstone disease in the elderly and to test possible predictors. METHODS: This is a single institution retrospective chart review of patients 65 years and older with an initial hospital visit (V1) for symptomatic gallstone disease, over a 4-year period. Patients with initial "non-operative" management were defined as those without surgery at V1 and without elective surgery at visit 2 (V2). Baseline characteristics included age, sex, Charlson comorbidity index (CCI), diagnosis, and interventions (ERCP or cholecystostomy) at V1. Outcomes assessed over 1 year were as follows: recurrence (any ER/admission visit following V1), surgery, complications, and mortality. A survival analysis using a Cox proportional hazards model was performed to assess predictors of recurrence. RESULTS: There were 195 patients initially treated non-operatively at V1. Mean age was 78.3 ± 7.8 years, 45.6% were male, and the mean CCI was 2.1 ± 1.9. At V1, 54.4% had a diagnosis of biliary colic or cholecystitis, while 45.6% had a diagnosis of cholangitis, pancreatitis, or choledocholithiasis. 39.5% underwent ERCP or cholecystostomy. Excluding 10 patients who died at V1, 31.3% of patients had a recurrence over the study period. Among these, 43.5% had emergency surgery, 34.8% had complications, and 4.3% died. Median time to first recurrence was 2 months (range 6 days-4.8 months). Intervention at V1 was associated with a lower probability of recurrence (HR 0.3, CI [0.14-0.65]). CONCLUSION: One-third of elderly patients will develop a recurrence following non-operative management of symptomatic biliary disease. These recurrences are associated with significant rates of emergency surgery and morbidity. Percutaneous or endoscopic therapies may decrease the risk of recurrence.

Formal research training during surgical residency: scaffolding for academic success.

BACKGROUND: The purpose of this study was to determine the impact of a formal surgical research program (leading to a postgraduate degree) during residency, on future research productivity. METHODS: We surveyed all North American graduates of the McGill University general surgery residency program between 1987 and 2005. The survey included questions on research involvement before, during, and after general surgery residency. This was combined with a literature search revealing all research publications of the participants. Outcomes were the yearly average of publications and awarded funding as faculty members. RESULTS: Seventy-five of 119 graduates (63%) responded. Staff physicians who had participated in formal research programs during residency (n = 35), compared with those who had not (n = 40), produced more publications per year (2.8 ± 2.3 vs 1.1 ± 1.2, P < .01) and had greater funding success (81% vs 55%, P = .03). CONCLUSIONS: Residents who had participated in formal research programs during residency were more likely to have greater academic success.

Knowing the operative game plan: a novel tool for the assessment of surgical procedural knowledge.

BACKGROUND: What is the source of inadequate performance in the operating room? Is it a lack of technical skills, poor judgment or a lack of procedural knowledge? We created a surgical procedural knowledge (SPK) assessment tool and evaluated its use. METHODS: We interviewed medical students, residents and training program staff on SPK assessment tools developed for 3 different common general surgery procedures: inguinal hernia repair with mesh in men, laparoscopic cholecystectomy and right hemicolectomy. The tools were developed as a step-wise assessment of specific surgical procedures based on techniques described in a current surgical text. We compared novice (medical student to postgraduate year [PGY]-2) and expert group (PGY-3 to program staff) scores using the Mann-Whitney U test. We calculated the total SPK score and defined a cut-off score using receiver operating characteristic analysis. RESULTS: In all, 5 participants in 7 different training groups (n = 35) underwent an interview. Median scores for each procedure and overall SPK scores increased with experience. The median SPK for novices was 54.9 (95% confidence interval [CI] 21.6-58.8) compared with 98.05 (95% CP 94.1-100.0) for experts (p = 0.012). The SPK cut-off score of 93.1 discriminates between novice and expert surgeons. CONCLUSION: Surgical procedural knowledge can reliably be assessed using our SPK assessment tool. It can discriminate between novice and expert surgeons for common general surgical procedures. Future studies are planned to evaluate its use for more complex procedures.

Are Canadian general surgery residents ready for the 80-hour work week? A nationwide survey.

BACKGROUND: The purpose of this study was to describe Canadian general surgery residents' perceptions regarding potential implementation of work-hour restrictions. METHODS: An ethics review board-approved, Web-based survey was submitted to all Canadian general surgery residency programs between April and July 2009. Questions evaluated the perceived effects of an 80-hour work week on length of training, operative exposure, learning and lifestyle. We used the Fisher exact test to compare senior and junior residents' responses. RESULTS: Of 360 residents, 158 responded (70 seniors and 88 juniors). Among them, 79% reported working 75-100 hours per week. About 74% of seniors believed that limiting their work hours would decrease their operative exposure; 43% of juniors agreed (p < 0.001). Both seniors and juniors thought limiting their work hours would improve their lifestyle (86% v. 96%, p = 0.12). Overall, 60% of residents did not believe limiting work hours would extend the length of their training. Regarding 24-hour call, 60% of juniors thought it was hazardous to their health; 30% of seniors agreed (p = 0.001). Both senior and junior residents thought abolishing 24-hour call would decrease their operative exposure (84% v. 70%, p = 0.21). Overall, 31% of residents supported abolishing 24-hour call. About 47% of residents (41% seniors, 51%juniors, p = 0.26) agreed with the adoption of the 80-hour work week. CONCLUSION: There is a training-level based dichotomy of opinion among general surgery residents in Canada regarding the perceived effects of work hour restrictions. Both groups have voted against abolishing 24-hour call, and neither group strongly supports the implementation of the 80-hour work week.

Laparoscopic splenectomy: learning curve comparison between benign and malignant disease.

BACKGROUND: New surgical techniques should be formally evaluated for feasibility and safety. As a model for this evaluation, this study examines the authors' institution's experience with splenectomy for benign and malignant hematologic disease since the introduction of laparoscopic splenectomy (LS) in 1996. The authors present the evaluation of the recognized surgeon/institutional learning curve using CUSUM (cumulative sum) analysis. METHODS: This is a single institution retrospective chart review of consecutive splenectomies for hematologic disease performed between 1996 and 2008. The primary outcome was conversion to open splenectomy. The learning curve for LS was evaluated using CUSUM analysis. RESULTS: A total of 123 splenectomies were performed for benign (51.2%) or malignant (48.7%) hematologic disease. 58% of patients underwent planned LS, with a 21% conversion rate. The surgeon's overall learning curves for LS, as well as that for malignant disease, were maintained within acceptable conversion thresholds. However, the learning curve for benign disease did cross the unacceptable conversion threshold at case 29. With additional experience, the curve again approached the acceptable conversion threshold. Patients with malignant disease were significantly older (P = .0004), had larger spleens (P = .0004), were more likely to undergo open splenectomy (P = .001), and had longer lengths of stay (P = .01). However, there was no significant difference in operative time, transfusion requirements, morbidity rates, or mortality rates between patients with benign and malignant disease. CONCLUSION: LS, for benign or for malignant hematologic disease, is associated with a significant learning curve. This evaluation model illustrates that careful patient selection and ongoing quality assessment is essential when introducing a new technique.

Gallstone disease in the elderly: are older patients managed differently?

BACKGROUND: This study aimed to describe the differences in the management of symptomatic gallstone disease within different elderly groups and to evaluate the association between older age and surgical treatment. METHODS: This single-institution retrospective chart review included all patients 65 years old and older with an initial hospital visit for symptomatic gallstone disease between 2004 and 2008. The patients were stratified into three age groups: group 1 (age, 65-74 years), group 2 (age, 75-84 years), and group 3 (age, ≥ 85 years). Patient characteristics and presentation at the initial hospital visit were described as well as the surgical and other nonoperative interventions occurring over a 1-year follow-up period. Logistic regression was performed to assess the effect of age on surgery. RESULTS: Data from 397 patient charts were assessed: 182 in group 1, 160 in group 2, and 55 in group 3. Cholecystitis was the most common diagnosis in groups 1 and 2, whereas cholangitis was the most common diagnosis in group 3. Elective admissions to a surgical ward were most common in group 1, whereas urgent admissions to a medical ward were most common in group 3. Elective surgery was performed at the first visit for 50.6% of group 1, for 25.6% of group 2, and for 12.7% of group 3, with a 1-year cumulative incidence of surgery of 87.4% in group 1, 63.5% in group 2, and 22.1% in group 3. Inversely, cholecystostomy and endoscopic retrograde cholangiopancreatography (ERCP) were used more often in the older groups. Increased age (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.84-0.91) and the Charlson Comorbidity Index (OR, 0.80; 95% CI, 0.69-0.94) were significantly associated with a decreased probability of undergoing surgery within 1 year after the initial visit. CONCLUSION: Even in the elderly population, older patients presented more frequently with severe disease and underwent more conservative treatment strategies. Older age was independently associated with a lower likelihood of surgery.

Conversion in laparoscopic cholecystectomy after gastric resection: a 15-year review.

BACKGROUND: Gastrectomy or truncal vagotomy is known to increase the incidence of cholelithiasis. Many of these patients will become symptomatic, and the adhesions from their gastric resection may make laparoscopic cholecystectomy much more difficult. METHODS: We prospectively assessed the data for the 15-year cumulative laparoscopic cholecystectomy experience of 1 surgeon at a university teaching hospital with respect to conversion and postoperative outcomes, with particular attention to patients having had previous gastric resections. RESULTS: Patients with previous gastrectomies had similar operative times (mean 81.1, range 45-120 min), a higher conversion rate (64.2%) and a higher complication rate (35.7%) than those who had had other previous upper abdominal surgeries (mean 73.2, range 35-130 min, conversion 25% and complication 11.3%) and those without previous abdominal surgeries (mean 66.5, range 25-250 min, conversion 2.7% and complication 4.5%). CONCLUSION: Preoperative knowledge of the increased conversion rate and increased morbidity will inform surgical planning for both the surgeon and the patient.

Evaluating intraoperative laparoscopic skill: direct observation versus blinded videotaped performances.

The Global Operative Assessment of Laparoscopic Skill (GOALS) has been shown to meet high standards for direct observation. The purpose of this study was to investigate the reliability and validity of GOALS when applied to blinded, videotaped performances. Five novice surgeons and 5 experienced surgeons were each evaluated by 2 observers during a laparoscopic cholecystectomy. Subsequently, 4 laparoscopists (V1 to V4) evaluated the videotaped procedures using GOALS. Two of the raters (V1 and V3) had prior experience using GOALS. The interrater reliabilities between video raters (VRs) and between VRs and direct raters (DRs) were calculated using the intraclass correlation coefficient. Construct validity was assessed using 2-way analysis of variance. Interrater reliability between the 4 VRs and the 2 DRs was 0.72. The intraclass correlation coefficient for the 4 VRs was 0.68 and for each VR compared with the mean DR was 0.86, 0.39, 0.94, and 0.76, respectively. All raters, except V2, differentiated between novice and experienced groups (P values ranged from .01 to .05). These data suggest that GOALS can be used to assess laparoscopic skill based on videotaped performances but that rater training may play an important role in ensuring the reliability and validity of the instrument. Experience with the tool in the operating room may improve the reliability of video rating and could be of value in training evaluators.

Ileocecal hobnail hemangioendothelioma: report of a case and review of the literature.

Hobnail hemangioendothelioma is a rare vascular neoplasm that belongs to the category of vascular neoplasms of borderline (or low-grade) malignancy, defined by a significant potential for local recurrence but very low numbers of metastatic or fatal events. It is typically found in the skin, and rarely in the oral mucosa of children and young adults. We report the first case of hobnail hemangioendothelioma located in the intestine (ileocecal valve).

Proving the value of simulation in laparoscopic surgery.

OBJECTIVE: To assess the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) physical laparoscopic simulator for construct and predictive validity and for its educational utility. SUMMARY BACKGROUND DATA: MISTELS is the physical simulator incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in their Fundamentals of Laparoscopic Surgery (FLS) program. MISTELS' metrics have been shown to have high interrater and test-retest reliability and to correlate with skill in animal surgery. METHODS: Over 200 surgeons and trainees from 5 countries were assessed using MISTELS in a series of experiments to assess the validity of the system and to evaluate whether practicing MISTELS basic skills (transferring) would result in skill acquisition transferable to complex laparoscopic tasks (suturing). RESULTS: Face validity was confirmed through questioning 44 experienced laparoscopic surgeons using global rating scales. MISTELS scores increased progressively with increasing laparoscopic experience (n = 215, P < 0.0001), and residents followed over time improved their scores (n = 24, P < 0.0001), evidence of construct validity. Results in the host institution did not differ from 5 beta sites (n = 215, external validity). MISTELS scores correlated with a highly reliable validated intraoperative rating of technical skill during laparoscopic cholecystectomy (n = 19, r = 0.81, P < 0.0004; concurrent validity). Novice laparoscopists were randomized to practice/no practice of the transfer drill for 4 weeks. Improvement in intracorporeal suturing skill was significantly related to practice but not to baseline ability, career goals, or gender (P < 0.001). CONCLUSION: MISTELS is a practical and inexpensive inanimate system developed to teach and measure technical skills in laparoscopy. This system is reliable, valid, and a useful educational tool.

Immediate postlaparotomy small bowel obstruction: a 16-year retrospective analysis.

Small bowel obstruction (SBO) is a particularly vexing problem in the postoperative period. The goal of this study was to compare the results of operative versus nonoperative treatment. A secondary goal was to explore risk factors for necessitating reoperation in the immediate postoperative period. We conducted a historical cohort retrospective chart review at a university-affiliated hospital. The medical records of patients treated between 1985 and 2000 at the Sir Mortimer B. Davis Jewish General Hospital (Montreal, Quebec, Canada) who developed SBO after undergoing a laparotomy during that admission were reviewed. Postoperative SBO was defined as cessation of flatus or bowel movements after their resumption following operation. To compare operative versus nonoperative management of early postoperative mechanical SBO we used the following outcome measures: Reoperation rate, time to return of function, length of stay, and mortality. Of 52 patients who developed SBO in the immediate postoperative period 37 were male, 25 had colorectal surgery, and nine had a gastrectomy as the initial operation on admission; five had inflammatory bowel disease, six had a previous SBO, 22 had virgin abdomens before the current operation, and 11 had adhesions noted at the initial operation. The median time to the development of obstructive symptoms was 8 days (range 1-33). The reoperation rate was 42 per cent overall (67% in women and 32% in men, P = 0.02). For operatively treated patients the median time between onset of symptoms and surgery was 5 days [range 1-23, interquartile range (IQR) = 5]. The median time to the return of bowel function was greater in the operatively treated patients compared with nonoperatively treated patients [11.5 days (range 4-37, IQR = 11) vs 6 days (range 1-28, IQR = 7), P < 0.0001] as was median length of stay from onset of obstruction [23 days (range 6-60, IQR = 14) vs 12 days (range 2-45, IQR = 16), P < 0.009]. Operatively treated patients also stayed longer after their obstruction was relieved although not significantly longer [8 days (range 1-35, IQR = 11) vs 4.5 days (range 0-40, IQR = 10), P = 0.15]. There were 11 complications in nine of 22 patients who underwent operative treatment of their SBO. Immediate postoperative SBO can be treated nonoperatively in stable patients resulting in significantly quicker return of bowel function and shorter lengths of hospital stay. Definitive risk factors for immediate SBO could not be identified.