Complication Is Inevitable, but Suffering is Optional-Psychological Aspects of Dealing with Complications in Surgery.

Surgical complications remain common in health care and constitute a significant challenge for hospitals, surgeons, and patients. While they cause significant physical, financial, and psychological harm to patients and their families, they also heavily burden the involved physicians. This phenomenon, known as the "second victim," results in negative short and long-term physical, cognitive, and psychological consequences on the surgeon. In this review, we explored the intricate connections between the surgeons' emotional response to adverse events concerning the patient outcome, perceived peer reaction, and existing social and institutional support systems. Using a selective literature review coupled with personal experiences, we propose a model of this complex interaction and suggest specific interventions to ameliorate the severity of response within this framework. The institution of the proposed interventions may improve the psychological well-being of surgeons facing complications and promote a cultural shift to better support physicians when they occur.

What's the incidence of delayed splenic bleeding in children after blunt trauma? An institutional experience and review of the literature.

BACKGROUND: The existence and incidence of delayed splenic bleeding (DSB) in children are controversial but the implications are significant. We sought to determine the incidence of DSB in children and to look for similarities between reported cases. METHODS: A retrospective cohort study of all children admitted from 1992 to 2006 to our level 1 pediatric trauma center with blunt splenic injuries to calculate the incidence of DSB. In addition, a systematic review of the literature was performed, looking for similarities between reported cases of DSB in children since 1980. RESULTS: Three hundred three children were admitted with blunt splenic injuries (mean age, 10 years +/- 4.5 years; boys 212 [70%]). Two hundred ninety-three (96%) were successfully managed nonoperatively. All-cause mortality was 20 of 303 (6.6%). We identified 1 of 303 (0.33%) children with DSB. The patient was a boy, aged 15 years. He presented 23 days after initial injury with DSB causing death. He had an uncomplicated admission after his initial grade IV injury. There have been 14 cases of DSB reported in the literature since 1980. Twelve (88%) were boys, with a mean age of 14 years +/- 4 years (with 11 of 14 (79%) being adolescent). The mean time to DSB was 10 days +/- 7 days. There were no similarities in mechanism, imaging characteristics, or presence of pseudoaneurysm between cases. CONCLUSION: DSB is exceedingly rare. Our institutional incidence is 1 of 303 (0.33%). The number and quality of reported cases is insufficient to draw conclusions on predisposing factors for DSB, however, most cases occur in adolescents.

Fast and accurate vision-based stereo reconstruction and motion estimation for image-guided liver surgery.

Image-guided liver surgery aims to enhance the precision of resection and ablation by providing fast localisation of tumours and adjacent complex vasculature to improve oncologic outcome. This Letter presents a novel end-to-end solution for fast stereo reconstruction and motion estimation that demonstrates high accuracy with phantom and clinical data. The authors' computationally efficient coarse-to-fine (CTF) stereo approach facilitates liver imaging by accounting for low texture regions, enabling precise three-dimensional (3D) boundary recovery through the use of adaptive windows and utilising a robust 3D motion estimator to reject spurious data. To the best of their knowledge, theirs is the only adaptive CTF matching approach to reconstruction and motion estimation that registers time series of reconstructions to a single key frame for registration to a volumetric computed tomography scan. The system is evaluated empirically in controlled laboratory experiments with a liver phantom and motorised stages for precise quantitative evaluation. Additional evaluation is provided through testing with patient data during liver resection.

Positioning the endoscope in laparoscopic surgery by foot: Influential factors on surgeons' performance in virtual trainer.

We have investigated how surgeons can use the foot to position a laparoscopic endoscope, a task that normally requires an extra assistant. Surgeons need to train in order to exploit the possibilities offered by this new technique and safely manipulate the endoscope together with the hands movements. A realistic abdominal cavity has been developed as training simulator to investigate this multi-arm manipulation. In this virtual environment, the surgeon's biological hands are modelled as laparoscopic graspers while the viewpoint is controlled by the dominant foot. 23 surgeons and medical students performed single-handed and bimanual manipulation in this environment. The results show that residents had superior performance compared to both medical students and more experienced surgeons, suggesting that residency is an ideal period for this training. Performing the single-handed task improves the performance in the bimanual task, whereas the converse was not true.

In a demanding task, three-handed manipulation is preferred to two-handed manipulation.

Equipped with a third hand under their direct control, surgeons may be able to perform certain surgical interventions alone; this would reduce the need for a human assistant and related coordination difficulties. However, does human performance improve with three hands compared to two hands? To evaluate this possibility, we carried out a behavioural study on the performance of naive adults catching objects with three virtual hands controlled by their two hands and right foot. The subjects could successfully control the virtual hands in a few trials. With this control strategy, the workspace of the hands was inversely correlated with the task velocity. The comparison of performance between the three and two hands control revealed no significant difference of success in catching falling objects and in average effort during the tasks. Subjects preferred the three handed control strategy, found it easier, with less physical and mental burden. Although the coordination of the foot with the natural hands increased trial after trial, about two minutes of practice was not sufficient to develop a sense of ownership towards the third arm.

Are some children with empyema at risk for treatment failure with fibrinolytics? A multicenter cohort study.

BACKGROUND: Guidelines recommend that children with empyema be treated initially with chest tube insertion and intrapleural fibrinolytics. Some patients have poor outcomes with this approach, and it is unclear which factors are associated with treatment failure. METHODS: Possible risk factors were identified through a review of the literature. Treatment failure was defined as need for repeat pleural drainage and/or total length of stay greater than 2weeks. RESULTS: We retrospectively identified 314 children with empyema treated with fibrinolytics at The Hospital for Sick Children (2000-2013, n=195), Children's Hospital, London Health Sciences Centre (2009-2013, n=39), and McMaster Children's Hospital (2007-2014, n=80). Median length of stay was 11days (range 5-69days). Thirteen percent of children required repeat drainage procedures, and 34% experienced treatment failure. There were no deaths. White blood cell count, erythrocyte sedimentation rate, C-reactive protein, albumin, urea to creatinine ratio, and signs of necrosis on initial chest x-ray were not associated with treatment failure. Multivariable logistic regression demonstrated increased risk with positive blood culture (odds ratio=2.7), immediate admission to intensive care (odds ratio=2.6), and absence of complex septations on baseline ultrasound (odds ratio=2.1). Male gender and platelet count were associated with treatment failure in the univariate analysis but not in the multivariable model. CONCLUSIONS: Predicting which children with empyema are at risk for treatment failure with fibrinolytics remains challenging. Risk factors include positive blood culture, immediate admission to intensive care, and absence of complex septations on ultrasound. Routine blood work and inflammatory markers have little prognostic value.

The evolving identity, capacity, and capability of the future surgeon.

Technology has transformed surgery more within the last 30 years than the previous 2000 years of human history combined. These innovations have changed not only how the surgeon practices but have also altered the very essence of what it is to be a surgeon in the modern era. Beyond the industrial revolution, today's information revolution allows patients access to an abundance of easily accessible, unfiltered information which they can use to evaluate their surgical treatment, and truly participate in their personal care. We are entering yet another revolution specifically affecting surgeons, where the traditional surgical tools of our craft are becoming "smart." Intelligence in surgical tools and connectivity based on sensory data, processing, and analysis are enabling and enhancing a surgeon's capacity and capability. Given the tempo of change, within one generation the traditional role and identity of a surgeon will be fully transformed. In this article, the impact of the information revolution, technological advances combined with smart connectivity on the changing role of surgery will be considered.

Is congenital cystic adenomatoid malformation a premalignant lesion for pleuropulmonary blastoma?

BACKGROUND: The relationship between congenital cystic adenomatoid malformation (CCAM) and pleuropulmonary blastoma (PPB), whether causal, correlational, or coincidental, remains controversial. There is a lack of consensus as to the optimal treatment of patients with asymptomatic CCAM. METHOD: We reviewed all cases of CCAM and PPB seen at our institution from 1999 to 2008. Institutional Research Ethics Board approval was obtained. The incidence of CCAM and PPB, respectively, was calculated based on birth numbers during the study period. RESULTS: Seventy-four CCAMs were resected over the study period in 129 children diagnosed with CCAM. Five PPBs were diagnosed during the study period. Three of the 5 PPB cases were initially diagnosed as CCAMs. These PPBs were not clinically or radiologically distinguishable from CCAMs. In our referral area, the incidence of CCAM was 1 in 12,000; and the incidence of PPB was 1 in 250,000 live births. The mortality rate for PPB in this cohort was 20%. CONCLUSION: Asymptomatic cystic lung malformations represent a therapeutic dilemma. In this cohort, the incidence of PPB among apparently benign lung lesions was 4%. No clinical or radiological markers differentiated benign CCAMs from PPBs. Our experience provides further justification for resection of all CCAMs. This should be discussed with parents until CCAMs and PPBs can be clearly distinguished preoperatively.

A single center 26-year experience with treatment of esophageal achalasia: is there an optimal method?

PURPOSE: Treatment modalities for achalasia are evolving and remain controversial. Herein, we report the relative efficacy and outcomes after dilatation or myotomy in children with achalasia. METHODS: A retrospective analysis of all children treated for achalasia at a tertiary center from 1981 to 2007 was performed (n = 40). Demographics, presenting symptoms, perioperative parameters, and outcomes were analyzed using t tests and chi(2) statistics. RESULTS: Thirty patients were initially treated by esophageal dilatation (ED), whereas 10 were treated by laparoscopic or open Heller myotomy (HM). Both groups were similar with respect to age (10.6 vs 12.4 years; P = .19). There were 18 males and 12 females in the ED group, compared to 5 males and 5 females in the HM group (P = .72). Mean duration of symptoms before diagnosis, including dysphagia, vomiting, food sticking, chest pain, and weight loss, was 15.9 months for ED and 10.7 months for HM (P = .41). Mean time from diagnosis to initial intervention was 76 days in ED vs 86 days in HM (P = .78). Subsequent interventions by myotomy or both dilatation and myotomy were required in 9 (30%) of 30 patients in the ED group and 2 (20%) of 10 patients in the HM group (P = .70). A clear transition from open to laparoscopic approach occurred between 1995 and 2001. Mean operating times were comparable (186.3 vs 156.0 minutes; P = .48). Of 14 laparoscopic myotomies, 11 (79%) had fundoplication, and 2 (18%) of the 11 were converted to open procedure. Intraoperative mucosal perforation rates were similar between open and laparoscopic groups (17% vs 18%). At follow-up, 32% of ED patients vs 43% HM had complete symptom relief (mean follow-up duration, 75.2 months; SD, 196.5). CONCLUSION: Both dilatation and myotomy are effective immediate treatment of achalasia. A clear transition to and preference for laparoscopic approach has occurred in the treatment of achalasia in children.

Absolute vs relative improvements in congenital diaphragmatic hernia survival: what happened to "hidden mortality".

PURPOSE: The aim of this study is to determine if there has been a true, absolute, or apparent relative increase in congenital diaphragmatic hernia (CDH) survival for the last 2 decades. METHOD: All neonatal Bochdalek CDH patients admitted to an Ontario pediatric surgical hospital during the period when significant improvements in CDH survival was reported (from January 1, 1992, to December 31, 1999) were analyzed. Patient characteristics were assessed for CDH population homogeneity and differences between institutional and vital statistics-based population survival outcomes. SAS 9.1 (SAS Institute, Cary, NC) was used for analysis. RESULT: Of 198 cohorts, demographic parameters including birth weight, gestational age, Apgar scores, sex, and associated congenital anomalies did not change significantly. Preoperative survival was 149 (75.2%) of 198, whereas postoperative survival was 133 (89.3%) of 149, and overall institutional survival was 133 (67.2%) of 198. Comparison of institution and population-based mortality (n = 65 vs 96) during the period yielded 32% of CDH deaths unaccounted for by institutions. Yearly analysis of hidden mortality consistently showed a significantly lower mortality in institution-based reporting than population. CONCLUSION: A hidden mortality exists for institutionally reported CDH survival rates. Careful interpretation of research findings and more comprehensive population-based tools are needed for reliable counseling and evaluation of current and future treatments.