Gideon Sroka

Fundamentals of Laparoscopic Surgery simulator training to proficiency improves laparoscopic performance in the operating room—a randomized controlled trial

BACKGROUND The purpose of this study was to assess whether training to proficiency with the Fundamentals of Laparoscopic Surgery (FLS) simulator would result in improved performance in the operating room (OR). METHODS Nineteen junior residents underwent baseline FLS testing and were assessed in the OR using a validated global rating scale (GOALS) during elective laparoscopic cholecystectomy. Those with GOALS scores <or=15 were randomly assigned to training (n = 9) or control (n = 8) groups. An FLS proficiency-based curriculum was used in the training group. Scoring on FLS and in the OR was repeated after the study period. Evaluators were blinded to randomization status. RESULTS Sixteen residents completed the study. There were no differences in baseline simulator (49.1 +/- 17 vs 39.5 +/- 16, P = .27) or OR scores (11.3 +/- 2.0 vs 12.0 +/- 1.8; P = .47). After training, simulator scores were higher in the trained group (95.1 +/- 4 vs 60.5 +/- 23, P = .004). OR performance improved in the control group by 1.8 to 13.8 +/- 2.2 (P = .04), whereas the trained group improved by 6.1 to 17.4 +/- 1.9 (P = .0005 vs control; P < .0001 vs baseline). CONCLUSIONS This study clearly demonstrates the educational value of FLS simulator training in surgical residency curricula.

How should we establish the clinical case numbers required to achieve proficiency in flexible endoscopy

BACKGROUND Recommended procedure numbers for upper endoscopy (UE) and colonoscopy (C) are 35 and 50 for surgical residents, and 130 and 140 for gastroenterology fellows, respectively. The purpose of this study was to challenge the methods used to determine proficiency in flexible endoscopy. METHODS Global assessment of gastrointestinal endoscopic skills (GAGES) was used to evaluate 139 procedures. Scores for UE were compared using self-reported case numbers and grouped according to requirements for each discipline. C scores were compared using the requirements to define novice and experienced endoscopists. Procedure volumes were plotted against GAGES scores. RESULTS Three groups were compared for UE based on case volumes: fewer than 35 cases (group 1), 35 to 130 cases (group 2), and more than 130 cases (group 3). There was no difference between group 2 (17.8 +/- 1.8) and group 3 (19.1 +/- 1.1), but both scored higher than group 1 (14.4 +/- 3.7; P < .05). For C, the scores were 11.8 +/- 3.8 (novices) and 18.8 +/- 1.34 (experienced; P < .001) at a 50-case minimum and 12.4 +/- 4.2 and 18.8 +/- 1.3 (P < .001) for a 140-case proficiency cut-off level, respectively. The curve of procedures versus GAGES plateaued at 50 (UE) and 75 (C). CONCLUSIONS The surgical and gastroenterology case recommendations may not represent the experience needed to achieve proficiency. GAGES scores could help define proficiency in basic endoscopy.

Performance of simulated laparoscopic incisional hernia repair correlates with operating room performance.

BACKGROUND the role of simulation for training in procedures such as laparoscopic incisional hernia repair (LIHR) is unknown. The purpose of this study was to determine whether performance in simulated LIHR correlates with operating room (OR) performance. METHODS subjects performed LIHR in the University of Maryland Surgical Abdominal Wall (SAW) simulator and the OR. Trained observers used a LIHR-specific global rating scale (Global Operative Assessment of Laparoscopic Skills-Incisional Hernia) to assess performance. Global Operative Assessment of Laparoscopic Skills-Incisional Hernia includes 7 domains (trocar placement, adhesiolysis, mesh sizing, mesh positioning, mesh fixation, knowledge and autonomy in instrument use, and overall competence). The correlation between simulator and OR performance was assessed using the Pearson coefficient. RESULTS fourteen surgeons from 2 surgical departments participated. Experienced surgeons (n = 9) were defined as attending surgeons and minimally invasive surgury (MIS) fellows, and novice surgeons (n = 5) were general surgery residents (postgraduate years 3-5). The correlation between performance in the OR and the simulator for the entire group was .87 (95% confidence interval, .63-.96; P < .001). CONCLUSIONS there was an excellent correlation between LIHR performance in the simulator and clinical LIHR. This suggests that performance in the SAW simulator may predict performance in the operating room.

Postoperative analgesia by adding acupuncture to conventional therapy, a non-randomized controlled trial

Abstract Background Postoperative pain is common in patients hospitalized in surgical departments, yet it is currently not sufficiently controlled by analgesics. Acupuncture, a complementary medical practice, has been evaluated for its benefits in postoperative pain with heterogeneous results. We tested the feasibility of a controlled study comparing the postoperative analgesic effect of acupuncture together with standard-of-care to standard-of-care only. Methods In this pilot non-randomized controlled study conducted at a tertiary medical center in Israel, patients received either acupuncture with standard-of-care pain treatment (acupuncture group) or standard-of-care treatment only (control group) following surgery. Visual Analogue Scale (VAS) ratings for pain level at rest and in motion were evaluated both at recruitment and two hours after treatment. Acupuncture-related side effects were reported as well. Results We recruited 425 patients; 336 were assigned to the acupuncture group and 89 to the control group. The acupuncture group exhibited a decrease of at least 40% in average level of pain both at rest (1.8±2.4, p<0.0001) and in motion (2.1±2.8, p<0.0001) following acupuncture, whereas the control group exhibited no significant decrease (p=0.92 at rest, p=0.98 in motion). Acupunctures analgesic effect was even more prominent in reducing moderate to severe pain at baseline (VAS ≥4), with a decrease of 49% and 45% of pain level at rest and in motion respectively (p<0.001), compared with no significant amelioration in the control group (p=0.20 at rest, p=0.12 in motion). No major side effects were reported. Conclusion Integrating acupuncture with standard care may improve pain control in the postoperative setting.

Hemorrhagic Complications in Laparoscopic Sleeve Gastrectomy.

Dear Editor, I read Dr. Mahawar’s letter to the editor with great interest. Apparently, we have shared a similar experience with regard to hemorrhagic complications after sleeve gastrectomy. We have both been very disturbed about patients we have had to take back to the OR due to bleeding. But it should be noted that the 2–3 % of patients who undergo re-operation due to bleeding are only a small portion of patients whose bleeding stopped without the need for re-operation. That is to say, the actual percentage of patients who experience bleeding is much higher than those undergoing re-operation. I do share Dr. Mahawar’s concerns about the possible late complications of bleeding, specifically leaks that appear late due to infected hematomas. Our study calls upon our colleagues to report complications accurately and systematically according to the Clavien-Dindo classification of complications. It is very true that our conclusionwould bemuch stronger if the blood pressure policy had been studied with a randomized controlled group, as we did for the reinforcement methods. The primary motivation for this study was to find a way to minimize bleeding complications after sleeve gastrectomy. We were concerned about which reinforcement method would be most efficient, and at the same time, we reviewed our videos and the anesthetist charts and came to the conclusion about the need to raise blood pressure while performing the hemostasis. It would definitely have been better to separate the two questions: one regarding the blood pressure policy and the other regarding the reinforcementmethod. Having said that, one should examine our control group, which showed a significant reduction in hemorrhagic complications compared to the previous cohort. The only difference between the two is the blood pressure policy. I believe this addresses Dr. Mahawar’s main concern. A few other points need to be made. Not all bariatric procedures have the same risk of stapler line bleeding. Gastric bypass and biliopancreatic diversion are procedures with a lower risk of bleeding. I assume the reason for this is that the sleeve has a longer stapler line that is based on the left and right gastric arteries and the staples are not vascular in nature. Our conclusion about the blood pressure control is indeed very important and unique in the surgical literature. At the same time, one should not underestimate the importance of the stapler line suture. A great deal is discussed in the literature about different reinforcement methods in sleeve gastrectomy, and none of these methods have led to better patient outcomes than the blood pressure policy and suturing together. Since the study ended, hundreds of patients have already undergone sleeve gastrectomy under these conditions with no apparent adverse events related to this policy. We will soon report these findings. I question whether it would be ethical to plan a randomized trial with a control group that did not enjoy the benefits of the blood pressure policy. I agree it might be interesting to investigate this policy in other surgical procedures, and I call upon our colleagues to collaborate in multi-center trials of this sort. Respectfully yours, Gideon Sroka, MD MSc Head, Laparoscopic Surgery Unit Bnai-Zion Medical Center Haifa, Israel * Gideon Sroka gideon.sroka@gmail.com

Israeli Arabs develop diverticulitis at a younger age and are more likely to require surgery than Jews

Background Only few studies have examined the impact of racial differences on the age of onset, course and outcomes of diverticulitis. Aim To provide data about the epidemiology of diverticulitis in northern Israel, and to determine whether ethnicity is a predictor of age of onset, complications, and need for surgery. Methods Was conducted a retrospective review of the charts of all patients diagnosed with a first episode of diverticulitis in our hospital between 2005 and 2012. Results Were found 638 patients with a first episode of acute diverticulitis in the eight year interval. Israeli Arabs developed a first episode of diverticulitis at a younger age compared to Jews (51.2 vs 63.8 years, p<0.01). Arabs living in rural areas developed diverticulitis at a younger age than Arabs living in urban centers (49.4 vs 54.5 years, P=0.03). Jewish and Arabic men developed diverticulitis at younger age compared to their female counterparts (59.9 vs 66.09, p<0.01, and 47.31 vs 56.93, p<0.01, respectively). Arabs were more likely [odds ratio (OR)=1.81 ,95% confidence interval (CI)1.12-2.90, p=0.017] than Jews to require surgical treatment (urgent or elective) for diverticulitis. Conclusions Israeli Arabs tend to develop diverticulitis at a younger age and are more likely to require surgical treatment for diverticulitis compared to Jews. Arabs living in rural areas develop diverticulitis at a younger age than Arabs living in urban centers. These findings highlight a need to address the root cause for ethnic differences in onset, course and outcome of acute diverticulitis.

INADVERTENT TATTOOING OF ADJACENT LARGE BOWEL: A CASE REPORT AND REVIEW OF LITERATURE

The increase in abdominal volume is slow, progressive and late noticed in some cases, mingling with ascites in about 18-20%. There are few reports of malignant mesenteric cysts, usually low-grade sarcomas. Kurtz et al. reviewed 162 cases and found only 3% of malignant transformation, all in adults. Are incidental findings during laparotomy or imaging, up to 40 % of cases. Acute abdomen occurs when there is rupture, infection, bleeding or twisting of the cyst, and confused with appendicitis or aortic aneurysm. Laboratory tests little help the diagnosis. Simple X-rays of the abdomen may show calcifications; arteriography and intestinal transit may show compressive mass. However, ultrasonography, computed tomography computed and magnetic resonance imaging are the exams that provide better diagnosis. Once diagnosed, all mesenteric cyst should be resected in order to avoid their complications 2-11 , recurrence, malignant transformation and possible complications (hemorrhage, torsion, obstruction, traumatic rupture and infection) 8-12 . Internal drainage may be an option when there is possibility of short bowel syndrome. In selected cases laparoscopic approach can be used 13-15 . Santana et al. 11 classified them as pathologically serous, bloodserous, chylous, with blood. In this case hydatid cist was also placed on judgment in the differential diagnosis, before the end of lymphangioma.