Denise W. Gee

The Teaching of Cultural Issues in U.S. and Canadian Medical Schools.

Purpose Despite the importance of culture in health care and the rapid growth of ethnic diversity in the United States and Canada, little is known about the teaching of cultural issues in medical schools. The study goals, therefore, were to determine the number of U.S. and Canadian medical schools that have courses on cultural issues, and to examine the format, content, and timing of those courses. Method The authors contacted the deans of students and/or directors of courses on cultural issues at all 126 U.S. and all 16 Canadian medical schools. Using a cross-sectional telephone survey, they asked whether each school had a course on cultural sensitivity or multicultural issues and, if so, whether it was separate or contained within a larger course, when in the curriculum the course was taught, and which ethnic groups the course addressed. Results The response rates were 94% for both U.S. (118) and Canadian (15) schools. Very few schools (U.S. = 8%; and Canada = 0%) had separate courses specifically addressing cultural issues. Schools in both countries usually addressed cultural issues in one to three lectures as part of larger, mostly preclinical courses. Significantly more Canadian than U.S. schools provided no instruction on cultural issues (27% versus 8%; p =.04). Few schools taught about the specific cultural issues of the largest minority groups in their geographic areas: only 28% and 26% of U.S. schools taught about African American and Latino issues, respectively, and only two thirds of Canadian schools taught about either Asian or Native Canadian issues. Only 35% of U.S. schools addressed the cultural issues of the largest minority groups in their particular states. Conclusions Most U.S. and Canadian medical schools provide inadequate instruction about cultural issues, especially the specific cultural aspects of large minority groups.

Natural orifice transesophageal mediastinoscopy and thoracoscopy

BackgroundThoracoscopy and mediastinoscopy are common procedures with painful incisions and prominent scars. A natural orifice transesophageal endoscopic surgical (NOTES) approach could reduce pain, eliminate intercostal neuralgia, provide access to the posterior mediastinal compartment, and improve cosmesis. In addition NOTES esophageal access routes also have the potential to replace conventional thoracoscopic approaches for medial or hilar lesions.MethodsFive healthy Yorkshire swine underwent nonsurvival natural orifice transesophageal mediastinoscopy and thoracoscopy under general anesthesia. An 8- to 9.8-mm video endoscope was introduced into the esophagus, and a 10-cm submucosal tunnel was created with blunt dissection. The endoscope then was passed through the muscular layers of the esophagus into the mediastinal space. The mediastinal compartment, pleura, lung, mediastinal lymph nodes, thoracic duct, vagus nerves, and exterior surface of the esophagus were identified. Mediastinal lymph node resection was easily accomplished. For thoracoscopy, a small incision was created through the pleura, and the endoscope was introduced into the thoracic cavity. The lung, chest wall, pleura, pericardium, and diaphragmatic surface were identified. Pleural biopsies were obtained with endoscopic forceps. The endoscope was withdrawn and the procedure terminated.ResultsMediastinal and thoracic structures could be identified without difficulty via a transesophageal approach. Lymph node resection was easily accomplished. Pleural biopsy under direct visualization was feasible. Selective mainstem bronchus intubation and collapse of the ipsilateral lung facilitated thoracoscopy. In one animal, an inadvertent 4-mm lung incision resulted in a pneumothorax. This was decompressed with a small venting intercostal incision, and the remainder of the procedure was completed without difficulty.ConclusionsTransesophageal endoscopic mediastinoscopy, lymph node resection, thoracoscopy, and pleural biopsy are feasible and provide excellent visualization of mediastinal and intrathoracic structures. Survival studies will be needed to confirm the safety of this approach.

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

Objective:To test the feasibility of implementing a standardized teamwork training program with full operating room teams in multiple institutions, driven by malpractice insurer support and incentives. Background:Failures in intraoperative teamwork are among the leading causes of preventable patient injury and death in surgical patients. Teamwork training, particularly using simulation, can be an effective intervention but is difficult to scale. Methods:A malpractice insurer convened a collaborative with 4 Harvard-affiliated simulation programs to develop a standardized operating room teamwork training curriculum, including principles of communication, assertiveness, and use of the World Health Organization Surgical Safety Checklist. Participant teams were compensated for lost operative time via malpractice premium discounts, continuing education credits, and compensation for lost wages. The course was delivered through a simulation program involving the management of intraoperative emergency scenarios. Participants were surveyed for their perceptions of the program and of its impact on clinical practice. Results:A total of 221 active operating room staff members participated in the program. Each team contained at least 1 attending surgeon, 1 attending anesthesiologist, and 1 operating room nurse (mean size per team: 7 ± 2 participants). No study dates were cancelled because of lack of attendance. The survey response rate was 99% (218/221). Overall, the vast majority of participants found the scenarios realistic [94% (95% confidence interval: 90.9%, 97.2%)], appropriately challenging [95.4% (92.6%, 98.2%)], relevant to their practice [96.3% (93.8%, 98.8%)], and found the training would help them provide safer patient care [92.6% (89.1%, 96.1%)]. Surgeons reported their greatest personal deficit as communication skills. Operating room nurses and anesthesiologists reported a greater need than surgeons to work on personal assertiveness. Conclusions:A standardized multicenter team training program involving full operative teams is feasible with high-fidelity simulation and modest compensation for lost time. The vast majority of the multidisciplinary participants believed the course to have had a meaningful impact on their approach to clinical practice.

Measuring the Effectiveness of Laparoscopic Antireflux Surgery: Long-term Results

OBJECTIVE To evaluate long-term results and quality of life of patients undergoing laparoscopic antireflux surgery. DESIGN A validated survey instrument, the Gastroesophageal Reflux Disease-Health-Related Quality-of-Life Scale (GERD-HRQL) was mailed to all patients who underwent laparoscopic fundoplications (LFs) from 1997 to 2006. Additional information was obtained regarding reintervention, satisfaction, and medication use. SETTING Tertiary care referral center. PATIENTS Four hundred five consecutive patients who underwent primary or redo LF from 1997 to 2006. MAIN OUTCOME MEASURES GERD-HRQL score, reoperation rate, and antireflux medication use. RESULTS A 54% response rate was obtained. Median follow-up was 60 months (range, 4-75 months). In patients who underwent primary LF, the mean (SD) GERD-HRQL score was 5.71 (7.99) (range, 0-45, with 0 representing no symptoms). Seventy-one percent of patients were satisfied with long-term results. Forty-three percent of patients took antireflux medications at some point following surgery; half of these patients had no diagnostic testing to document GERD recurrence. Only 3 patients (1.2%) required reoperation. Patients undergoing redo LF had higher GERD-HRQL scores (mean [SD], 14.25 [10.33]), lower satisfaction (35%), and greater probability of requiring antireflux medication (78%). Patients with body mass indexes (BMIs) (calculated as weight in kilograms divided by height in meters squared) between 25 and 35 had lower GERD-HRQL scores than thin (BMI < 25) and morbidly obese (BMI >/= 35) patients. CONCLUSIONS Contrary to the medical literature, our results demonstrate that patients undergoing primary LF by an experienced surgical team have near-normal GERD-HRQL scores at long-term follow-up and low reoperation rates and are satisfied with their decision to undergo surgery. Results following redo LF are not as good, highlighting the importance of proper patient selection and surgical technique when performing primary LF.

The effect of defined auditory conditions versus mental loading on the laparoscopic motor skill performance of experts

BackgroundMusic and noise are frequent occurrences in the operating room. To date, the effects of these auditory conditions on the performance of laparoscopic surgery experts have not been evaluated.MethodsEight internationally recognized experts were recruited for a crossover study. The experts were randomized to perform three simple tasks on a laparoscopic simulator, SurgicalSIM VR. The tasks were equal in difficulty and performed under the following conditions: silence, dichaotic music (auditory stress), classical music (auditory relaxation), and mental loading (mental arithmetic tasks). Permutations of the conditions were created to account for a learning effect. The tasks were performed twice to test for memory consolidation and to accommodate baseline variability. Time until task completion and task accuracy via instrument tip trajectory (path of the tip through space) were recorded. Performance was correlated with responses on the Brief Musical Experience Questionnaire (MEQ).ResultsThe study demonstrated that dichaotic music has a negative impact on time until task completion but not on task accuracy. In addition, memory consolidation of accuracy is negatively influenced. Classical music has a variable effect on experts’ time until task completion, yet all the experts performed the tasks more accurately. Classical music had no effect on recall of a procedure. Mental loading increased time until completion, but did not affect accuracy or recall. The experience of music varied among experts and influenced how each of the conditions affected their performance.ConclusionThe study demonstrated that, contrary to common belief, proficiency in surgery does not protect against stressful auditory influences or the influence of mental preoccupation. Interestingly, relaxing auditory influences such as classical music can even have a positive impact on the accuracy of experts. Previous musical experience could help to identify surgeons whose performance may be specifically affected by music or noise.

Natural orifice versus conventional laparoscopic distal pancreatectomy in a porcine model: a randomized, controlled trial

BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) research has primarily involved case series reports of low-risk procedures. Distal pancreatectomy has significant postoperative morbidity and would permit rigorous examination in a controlled trial setting. OBJECTIVE To compare endoscopic transgastric distal pancreatectomy (ETDP) and laparoscopic distal pancreatectomy (LDP). DESIGN Prospective, randomized, controlled trial. SETTING Academic hospital. SUBJECTS Forty-one swine, 28 block randomized. INTERVENTIONS LDP was performed with 3 trocars and stapled transection of the pancreas. ETDP was performed via a gastrotomy, with 1 trocar for visualization, by using endoloop placement, snare transection, and purse-string gastrotomy closure. MAIN OUTCOME MEASUREMENTS Clinical examination, CT, serum chemistries, necropsy, peritoneal fluid analysis, and histologic examination. RESULTS Swine were survived for 8 days. The procedure time for ETDP was significantly greater than for LDP (1:52 vs 0:33 [hours:minutes]; P = .00). Pancreatic specimen weight was similar (4.1 g vs 5.5 g; P = .108). Postoperatively, 26 of 28 animals thrived. In the LDP group, 1 death caused by pancreatic leak and renal failure occurred on day 1. In the ETDP group, 1 death caused by pneumothorax occurred intraoperatively. The necropsy, CT, and histologic examinations revealed focal resection-margin necrosis in 3 to 7 swine in the ETDP group with no proximal necrosis or pancreatitis. The groups were equivalent clinically, by survival, and by serum and peritoneal fluid analysis. The gastrotomy closure was associated with small serosal adhesions, but no gross abscess or necrosis. LIMITATION Animal study. CONCLUSIONS In the largest controlled trial of NOTES orifice surgery to date, there was no clinical or survival difference between NOTES and laparoscopic approaches.

Feasibility of endoscopic transesophageal thoracic sympathectomy (with video)

BACKGROUND Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain. OBJECTIVE To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model. DESIGN Nonsurvival animal study. SETTING Animal trial at a tertiary care academic center. SUBJECTS This study involved 8 healthy Yorkshire swine. INTERVENTIONS After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal thoracic sympathectomy. RESULTS The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability. LIMITATIONS Nonsurvival series, animal study. CONCLUSIONS Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.

Pouchitis in a rat model of ileal J pouch–anal anastomosis

Endorectal ileal pouch–anal anastomosis (IPAA) has become the operation of choice for patients with chronic ulcerative colitis. Although this procedure improves the quality of life, pouchitis remains a significant postoperative complication. Because our understanding of the pathophysiology of pouchitis may, in part, be due to the lack of small animal model, our aim was to develop a model of IPAA in a rat that mimics its clinical counterpart. Colectomy, proctectomy, construction of an ileal J pouch, and ileal pouch–rectal anastomosis as a model of IPAA was performed in Sprague-Dawley and Lewis rats. Radiographic contrast studies were performed to quantitate intestinal transit. The presence of activated neutrophils was quantified by measuring mucosal myeloperoxidase (MPO) activity. Oxidative stress was quantitated by measuring urinary 8-isoprostane (8-IP) levels. Anaerobic and aerobic bacterial counts were determined on Brucella and tryptic soy agar plates, respectively. Dextran sulfate sodium (DSS) was used to exacerbate ileal J pouch inflammation. Mortality was low, and animals gained weight normally after recovery. Stasis was documented radiographically. MPO levels were elevated (p < 0.05) in the ileal J pouch 30 and 60 days after IPAA, indicating an inflammation that was associated with stasis and bacterial overgrowth. 8-IP levels were elevated by 80% compared with controls. Oral administration of 5% DSS to IPAA rats with further elevated MPO and 8-IP levels in concert with a pouchitis-like syndrome that included the physical, gross, and histologic characteristics of clinical pouchitis. An understanding of the pathophysiology of pouchitis is essential to the future development of new therapeutic modalities. This model is applicable to investigating several key etiologic mechanisms purportedly related to pouchitis.

A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site

BACKGROUND Secure esophagotomy closure methods are a critical element in the advancement of transesophageal natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE To compare the clinical outcomes in swine receiving an esophageal stent or no stent after a submucosal tunnel NOTES access procedure. DESIGN Prospective, randomized, controlled trial in 10 Yorkshire swine. SETTING Academic center. INTERVENTION An endoscopic mucosectomy device was used to create an esophageal mucosal defect. An endoscope was advanced through a submucosal tunnel into the mediastinum and thorax, and diagnostic mediastinoscopy and thoracoscopy were performed. Ten animals were randomized to no stenting (n = 5) or stenting (n = 5) with a prototype small-intestine submucosa-covered stent. MAIN OUTCOME MEASUREMENTS Gross and histologic appearance of the mucosectomy and esophagotomy sites as well as clinical outcomes. RESULTS There was a significant difference in the overall procedure time between the animals that received a stent (35.0 min, range 27-46.0 min) and those with no closure (19.0 min, range 17-32 min) (P value = .018). The unstented group achieved endoscopic and histologic evidence of complete re-epithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). Stent migration into the stomach occurred in two swine. Both groups had complete closure of the submucosal tunnel and well-healed esophagotomy sites. LIMITATIONS Animal study, small number of subjects. CONCLUSION The placement of a covered esophageal stent significantly interferes with mucosectomy site healing.

Endoscopic transesophageal mediastinal lymph node dissection and en bloc resection by using mediastinal and thoracic approaches (with video)

BACKGROUND The criterion standard for sampling mediastinal lymph nodes is cervical mediastinoscopy. Current methods that require transthoracic or cervical incisions can result in significant postoperative pain. OBJECTIVE To determine the feasibility of a novel, transesophageal endoscopic technique for mediastinal lymph node dissection and en bloc resection. DESIGN Nonsurvival and survival animal study. SETTING Animal trial at a tertiary-care academic center. SUBJECTS This study involved 12 Yorkshire swine. INTERVENTION An endoscopic cap band mucosectomy device was used to create an esophageal mucosal defect. By using the tip of the endoscope and biopsy forceps, a submucosal tunnel was fashioned, and, within the submucosal space, a hook-knife incised the muscular esophageal wall. The endoscope was then advanced into the mediastinum and chest. Mediastinoscopy and thoracoscopy were performed to identify lymph node stations. Prototype endoscopic devices permitted lymph node dissection prior to removal with an electrocautery snare. A covered prototype stent was placed over the mucosectomy site. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal lymphadenectomy. RESULTS Three lymph nodes (1 para-aortic and 2 right paratracheal) were removed in the 3 nonsurvival swine. Nine swine were survived for 14 days (range 13-14 days) and had a total of 7 lymph nodes (2 para-aortic and 5 paratracheal) removed. Two swine had no endoscopically visible lymph nodes in the mediastinum or chest. Lymph node dissection and resection was successful in all cases where lymph nodes were identified. Lymphadenectomy was completed in a median time of 20.0 minutes (range 8-60 minutes); median total procedure time was 70.0 minutes (range 28-105 minutes). Median lymph node size was 1.1 cm (range 0.6-1.4 cm). LIMITATIONS Animal study. CONCLUSION An endoscopic transesophageal approach can accomplish mediastinal lymph node dissection and en bloc resection and provides architecturally intact lymph node specimens for histologic examination.