Jahnavi Srinivasan

Successful treatment of chronic Pouchitis utilizing fecal microbiota transplantation (FMT): a case report.

Dear Editor: Ulcerative colitis (UC) is a chronic debilitating inflammatory condition medically treated with corticosteroids, aminosalicylates, immunomodulators, and biologics. Almost one third of UC patients ultimately require surgical interventions because of fulminant colitis, dysplasia, cancer, or medical refractory diseases. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the current standard surgical intervention for severe chronic ulcerative colitis with failed medical treatment. Anastomotic leak, pouch failure, pelvic sepsis, and pouch ischemia can occur after the procedure. The most common long-term complication is pouchitis, an idiopathic inflammatory condition involving the ileal reservoir. Common presentations of pouchitis include increased stool frequency, urgency, incontinence, bloody stools, abdominal or pelvic discomfort, fatigue, malaise, and fever. The prevalence of pouchitis ranges from 23 to 46 %, with an annual incidence up to 40%. Though the majority of initial cases of pouchitis can be easily managed with a short course of antibiotics, in about 5 % of patients, inflammation of the pouch becomes chronic and a challenging problem tomanage. Fecal microbiota transplantation (FMT) is a novel therapy to transfer normal intestinal flora from a healthy donor to a patient with a medical condition potentially caused by disrupted homeostasis of intestinal microbiota or dysbiosis. FMT has been widely used in refractory Clostridium difficile infection (CDI) and recently it has gained popularity for treatment of inflammatory bowel disease (IBD). Previous studies suggested that manipulating the composition of intestinal flora through antibiotics, probiotics, and prebiotic achieved significant results for treating acute episodes of UC-associated pouchitis. However, currently there is no established effective treatment for chronic antibioticdependent or refractory pouchitis. In this report, we described a case of chronic antibiotic refractory pouchitis successfully treated with FMT through pouchoscopy. The effect has been sustainable at 6 months post-FMT.

Designing an ethics curriculum to support global health experiences in surgery.

BACKGROUND The field of global health is rapidly expanding in many medical centers across the US. As a result, medical students have increasing opportunities to incorporate global health experiences (GHEs) into their medical education. Ethics is a critical component of global health curricula, yet little literature exists to direct the further development of didactic training. Therefore, we sought to define ethical encounters experienced by medical students participating in short-term surgical GHEs and create a framework for the design of ethics curriculum specific to global surgery. MATERIALS AND METHODS Emory University Departments of Surgery, Urology, and Anesthesia, in partnership with the non-profit organization Project Medishare, have taken annual humanitarian surgical trips to Hinche, Haiti. All medical students returning from the trips in 2011 and 2012 received a 35-question survey to assess demographic data, extent of prior ethics education, frequency of exposure and situational confidence to ethical subject matter, as well as ethical conflicts involved in surgical GHEs. The same comparative data were also collected for domestic clinical clerkships. RESULTS Seventeen out of 21 medical students completed the survey. Nearly all (88.3%) students had previous formal ethics training as an undergraduate or in medical school. Ethical issues were commonly encountered during domestic clinical encounters and volunteerism. However, students reported enhanced exposure to the professional obligation of surgeons (P = 0.025) and truth-telling/surgeon-patient relationships (P = 0.044) during surgical volunteerism. Despite increased exposure, situational confidence did not change. CONCLUSIONS Ethical issues are commonly confronted during GHEs in surgery and differ from domestic clinical encounters. Healthcare ethics curriculum should be designed to meet the needs of medical students involved in global health.

Intensive medical student involvement in short-term surgical trips provides safe and effective patient care: a case review

BackgroundThe hierarchical nature of medical education has been thought necessary for the safe care of patients. In this setting, medical students in particular have limited opportunities for experiential learning. We report on a student-faculty collaboration that has successfully operated an annual, short-term surgical intervention in Haiti for the last three years. Medical students were responsible for logistics and were overseen by faculty members for patient care. Substantial planning with local partners ensured that trip activities supplemented existing surgical services. A case review was performed hypothesizing that such trips could provide effective surgical care while also providing a suitable educational experience.FindingsOver three week-long trips, 64 cases were performed without any reported complications, and no immediate perioperative morbidity or mortality. A plurality of cases were complex urological procedures that required surgical skills that were locally unavailable (43%). Surgical productivity was twice that of comparable peer institutions in the region. Student roles in patient care were greatly expanded in comparison to those at U.S. academic medical centers and appropriate supervision was maintained.DiscussionThis demonstration project suggests that a properly designed surgical trip model can effectively balance the surgical needs of the community with an opportunity to expose young trainees to a clinical and cross-cultural experience rarely provided at this early stage of medical education. Few formalized programs currently exist although the experience above suggests the rewarding potential for broad-based adoption.

Cadaver-Based Simulation Increases Resident Confidence, Initial Exposure to Fundamental Techniques, and May Augment Operative Autonomy

OBJECTIVE Surgical simulation is an important adjunct in surgical education. The majority of operative procedures can be simplified to core components. This study aimed to quantify a cadaver-based simulation course utility in improving exposure to fundamental maneuvers, resident and attending confidence in trainee capability, and if this led to earlier operative independence. DESIGN A list of fundamental surgical procedures was established by a faculty panel. Residents were assigned to a group led by a chief resident. Residents performed skills on cadavers appropriate for PGY level. A video-recorded examination where they narrated and demonstrated a task independently was then graded by attendings using standardized rubrics. Participants completed surveys regarding improvements in knowledge and confidence. SETTING The course was conducted at the Emory University School of Medicine and the T3 Laboratories in Atlanta, GA. PARTICIPANTS A total of 133 residents and 41 attendings participated in the course. 133 (100%) participating residents and 32 (78%) attendings completed surveys. RESULTS Resident confidence in completing the assigned skill independently increased from 3 (2-3) to 4 (3-4), p < 0.01. Residents stated that a median of 40% (interquartile range: 20%-60%) of procedures were performed for the first time in the course, and the same number had been performed only in the course. The percentage of skills attendings believed residents could perform independently increased from 40% (40%-60%) to 60% (60%->80%), p < 0.04. Attendings were more likely to grant autonomy in the operating room after this exercise (4 [3-5]). CONCLUSIONS A cadaveric skills course focused on fundamental maneuvers with objective confirmation of success is a viable adjunct to clinical operative experience. Residents were formally exposed to fundamental surgical maneuvers earlier as a result of this course. This activity improved both resident and attending confidence in trainee operative skill, resulting in increased attending willingness to grant a higher level of autonomy in the operating room.

Emory global surgery program: learning to serve the underserved well.

Over the past 25 years, there has been a surge in interest andactivity surrounding surgery in public health, the globalsurgical workforce, and the availability and quality ofsurgical services in low-resource settings. Significant researchand encouraging progress has been made on numerousfronts, from studies quantifying various aspects of theburden of surgical disease to innovative projects buildingand strengthening surgical capacity.

Learning from Haiti

In May, 2010, a 37-year-old woman, displaced from Port-au-Prince after the January earthquake, presented to Hopital St Therese in Hinche, Haiti, with a 2-year history of a slowly growing abdominal mass with associated dyspepsia, intermittent abdominal pain, anorexia, and weight loss. Her surgical history included four caesarean section deliveries and tubal ligation. Physical examination found her in no acute distress, with stable vital signs and a large, mobile abdominal mass extending to the subhepatic space. Haemoglobin was 106 g/L. A handwritten ultrasonography report from Port-au-Prince before the earthquake reported that she had a 10 cm mass with no further description, although on physical examination the mass was palpated at twice that size. No other laboratory or imaging capabilities were available. With no intensive care capabilities and limited transfusion supplies, local physicians had deferred surgery owing to diagnostic uncertainty. In July, 2010, a humanitarian surgical team brought a portable ultrasonography device to Hinche. Imaging of our patient showed a well-circumscribed, homogeneous, hypoechoic mass without invasion of adjacent structures (fi gure). The surgeons felt comfortable doing an exploratory laparotomy which revealed a well-demarcated, cystic ovarian mass, about 20 cm in diameter, resected via right oophorectomy (webappendix). Gross examination was consistent with a simple ovarian cyst. Diff erential diagnosis included ovarian and uterine tumours, pancreatic pseudocyst, and mesenteric cyst. She was discharged 2 days later with follow-up by local physicians. Our patient’s case demon strated the usefulness of portable devices in resource-limited settings. The well-circumscribed appearance of the mass and lack of invasion of adjacent structures provided enough supplementary information for surgeons to proceed safely at Hopital St Therese despite limited resources. Further delay in treatment would have resulted in persistent disability and possible torsion. In February, 2011, at last follow-up, she had had no complications. Diagnostic ultrasonography is a recognised, costeff ective aid for procedure-based care in under-resourced areas of the world. However, access to ultrasonography in these settings is limited. While we were in Haiti, ultrasonography also aided in the evaluation of soft-tissue masses, peritoneal disease, and uterine pathology. We recognise limitations of ultra sonography in these settings. Durability, weight, battery life, and ease of use all hindered our use of the device, but the greatest limitation of ultrasonography is cost. Although an aff ordable imaging modality, eff ective ultrasonography requires proper training, and the costs of both equipment and training can still exceed the budget for care of patients outside the industrialised world. Ideally, local physicians would be trained in diagnostic and therapeutic ultrasonographic techniques to allow for the continued benefi t of the local population. Although investment in both equipment and training would be needed, eff orts to implement programmes with portable ultrasonography in Tanzania and Rwanda have shown initial success, and we believe ultrasonography can play a vital role in resource-poor settings.

Pediatric short bowel syndrome and subsequent development of inflammatory bowel disease: an illustrative case and literature review.

Short bowel syndrome (SBS) in neonates is an uncommon but highly morbid condition. As SBS survival increases, physiologic complications become more apparent. Few reports in the literature elucidate outcomes for adults with a pediatric history of SBS. We present a case report of a patient, born with complicated gastroschisis resulting in SBS at birth, who subsequently developed symptoms and pathologic changes of inflammatory bowel disease (IBD) as an adult. The patient lived from age 7, after a Bianchi intestinal lengthening procedure, to age 34 independent of parenteral nutrition (PN), but requiring hydration fluid via G-tube. He was then diagnosed with IBD, after presenting with weight loss, diarrhea, and malabsorption, which required resumption of PN and infliximab treatment. This report adds to a small body of the literature which points to a connection between SBS in neonates and subsequent diagnosis of IBD. Recent evidence suggests that SBS and IBD have shared features of mucosal immune dysfunction and altered intestinal microbiota. We review current treatment options for pediatric SBS as well as multidisciplinary and coordinated transition strategies. We conclude that there may be an etiologic connection between SBS and IBD and that this knowledge may impact outcomes and approaches to care.

Perspective of a Program Director

Once a student has made the choice to embark on a career in surgery, the next step is to figure out how to choose the training program that is the right fit. Just as each applicant is unique, so is each program. That being said, all surgical residencies value a certain set of core characteristics in common. This chapter gives the perspective of a surgical program director on qualities that make for a successful surgery resident.

Trauma consults on humanitarian surgery trips: A perspective on the Haitian trauma system and the humanitarian’s role

Ubiquitous access to surgical care, especially trauma surgery, is recognized as an essential component of public health. We present two trauma cases—an upper arm machete laceration and a penetrating chest wound—that highlight barriers facing trauma patients in Haiti and describe how it relates to humanitarian surgery trips. An Emory University student–faculty collaborative, partnering with the non-profit Project Medishare (PM) for Haiti since 2008, provides elective and urgent surgical care to the underserved population of the Haitian Central Plateau. This partnership collaborates with a main referral center known for providing quality surgical care at little or no cost. Elective urological and general surgical cases comprise the bulk of the case load but urgent trauma services have been provided when required. Future trauma system initiatives must focus on increasing access to vehicles, telecommunications, and first responders. Our recommendations are reinforced by preliminary results from a trauma needs assessment performed in the Central Plateau and surrounding departments during July 2013. Humanitarian teams can contribute by preparing for emergencies prior to departure and sharing new procedural knowledge with local providers. Supplementing the ability to intercede in emergency surgical situations furthers the goal of short-term surgical trips to diminish indigenous patient morbidity and mortality. We advocate extensive preparation for such situations and increased bidirectional knowledge sharing with local staff.

Inherent Difficulties of Measuring the Burden of Surgical Disease in Resource-Poor Settings

Manganiello et al. [1] recently reported results of a first-ofits-kind study to capture the general burden of urologic disease in rural Haiti. The study highlighted that the burden of surgical disease in resource-poor settings has been difficult to quantify and that subspecialty data are particularly sparse. This paucity of data limits global health policymakers’ ability to focus more efforts on surgical therapeutics [2, 3]. The authors’ investigation represents the increased recognition that descriptive studies are the necessary foundation for further addressing the global burden of surgical disease. Manganiello et al. [1] appropriately highlighted many of the limitations of their study, such as the referral bias at Cange, the lack of outpatient data, and a short study interval. The authors noted that their study may have underestimated the burden of urologic disease but is still useful as a starting point for expanding the role of urologists in global surgery [1]. The limitations of the study’s findings may extend further, however. For the last 5 years, Emory Medishare has conducted its own humanitarian surgical trips to Hinche. Our experience suggests that Manganiello et al.’s methodology might not have captured the complete scope of urologic disease and available surgical care in a manner that provides clear policymaking guidance. These concerns arise from interpretive differences between Manganiello et al. and our previously reported case series [4]. Our team addressed urologic cases in Partners in Health/Zanmi Lasante’s (PIH/ZL) Hospital in Hinche during 2 of the 13 months included in Manganiello et al.’s study. All of our cases were documented for the hospital’s medical records office. Through work with PIH/ZL and other local partners, we found no local urologic expertise in Haiti’s Plateau Central and virtually no possibility of outpatient follow-up for urologic care. Similarly, the lack of urologic specialists may be countrywide as a number of our patients had traveled to Hinche from as far away as Port-au-Prince or Cap-Haı̈tien for complex urologic surgical care [5]. Our experience suggests that foreign ad hoc teams with urologic expertise provide much of the urologic care in rural Haiti. The conclusions drawn by Manganiello et al. about care decisions (e.g., open versus transurethral prostatic resection, general surgeon versus urologist) are limited by a care environment that consists of an unpredictable mix of equipment and personnel. Manganiello et al.’s work is both novel and ambitious, and the authors are to be commended. However, without comprehensive medical records—commonplace in developed countries—measurements often depend on documentation collected from third parties. Comparing Manganiello et al.’s regional study to our own operative case series highlights the quality attrition that occurs as one tries to scale up burden-of-disease metrics. The design of policies and initiatives to address the underrecognized burden of surgical disease are dependent on the global surgery community building surveillance systems that better capture realities on the ground. I. L. Leeds (&) L. A. Hugar C. A. Lorentz J. Srinivasan J. G. Pattaras V. A. Master Emory Medishare, Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30322, USA e-mail: ileeds@emory.edu