James Turner

Reducing the Inappropriate Use of Parenteral Nutrition in an Acute Care Teaching Hospital

BACKGROUNDnParenteral nutrition (PN) is a form of nutrition that can be life-saving, but its use has inherent risks and it is expensive. Nutrition support teams have been shown to reduce both the rate of complications and excessive use of PN.nnnMETHODSnCriteria were established to evaluate the appropriateness of PN use in a 487-bed community teaching hospital. A prospective study of 50 consecutive patients, who received either central or peripheral PN, was conducted.nnnRESULTSnThe 50 patients received 469 days of PN. We found that 233 (49.7%) of the 469 days of PN were avoidable. This resulted in the creation of a formal approval process that required prior approval by a physician-directed multidisciplinary advisory committee before PN could be instituted. The amount of PN subsequently decreased from 500 patient days of PN per month to less than 100.nnnCONCLUSIONSnThis study supports the idea that inappropriate use of PN can be reduced by physician education plus the continuing oversight of a physician-directed multidisciplinary advisory group.

Model for teaching laparoscopic colectomy to surgical residents

BACKGROUNDnThis study was undertaken to determine the impact that a resident teaching model for advanced laparoscopic skills has on performance, using outcome for laparoscopic colectomy as an indicator of efficacy.nnnMETHODSnSix senior surgical residents took part in a model for teaching advanced laparoscopic procedures over 3 years. Animal laboratory sessions, tutorial sessions, and feedback were the principle components of this model with residents evaluating each component and their operative experiences. Conversion rates, hospital length of stay, and operating time during the 3 years (n = 100) were compared with a previous year (baseline year) where the faculty performed most of a procedure (n = 20).nnnRESULTSnEach resident performed an average of 17 cases, being the primary surgeon after the sixth case. There were no differences in operative time for both right and left colectomies compared with the baseline year. Postoperative length of stay was less than 5 days by year 3, with a 14% conversion rate to open surgery. Feedback and tutorials were deemed most important for strategic planning and for reducing operative time.nnnCONCLUSIONSnResident participation in advanced laparoscopic surgery, concurrent with structured skills development and feedback, portends very favorable outcomes.

Team Play in Surgical Education: A Simulation-Based Study

BACKGROUNDnSimulation-based training provides a low-stress learning environment where real-life emergencies can be practiced. Simulation can improve surgical education and patient care in crisis situations through a team approach emphasizing interpersonal and communication skills.nnnOBJECTIVEnThis study assessed the effects of simulation-based training in the context of trauma resuscitation in teams of trainees.nnnMETHODSnIn a New York State-certified level I trauma center, trauma alerts were assessed by a standardized video review process. Simulation training was provided in various trauma situations followed by a debriefing period. The outcomes measured included the number of healthcare workers involved in the resuscitation, the percentage of healthcare workers in role position, time to intubation, time to intubation from paralysis, time to obtain first imaging study, time to leave trauma bay for computed tomography scan or the operating room, presence of team leader, and presence of spinal stabilization. Thirty cases were video analyzed presimulation and postsimulation training. The two data sets were compared via a 1-sided t test for significance (p < 0.05). Nominal data were analyzed using the Fischer exact test.nnnRESULTSnThe data were compared presimulation and postsimulation. The number of healthcare workers involved in the resuscitation decreased from 8.5 to 5.7 postsimulation (p < 0.001). The percentage of people in role positions increased from 57.8% to 83.6% (p = 0.46). The time to intubation from paralysis decreased from 3.9 to 2.8 minutes (p < 0.05). The presence of a definitive team leader increased from 64% to 90% (p < 0.05). The rate of spine stabilization increased from 82% to 100% (p < 0.08). After simulation, training adherence to the advanced trauma life support algorithm improved from 56% to 83%.nnnCONCLUSIONSnHigh-stress situations simulated in a low-stress environment can improve team interaction and educational competencies. Providing simulation training as a tool for surgical education may enhance patient care.

Palladium‐103: A new radioactive source in the treatment of unresectable carcinoma of the pancreas: A phase I–II study

Palladium‐103 (Pd‐103) is introduced in brachytherapy procedures because of its favorable physical properties, including its low energy, rapid dose fall‐off, short half‐life, and total cumulative dose delivery at a higher dose rate than iodine‐125 (I‐125) isotope. Intraoperative brachytherapy using I‐125 pellets was reported to provide significant palliation and meaningful prolongation of life in highly selected patients with unresectable carcinoma of the pancreas. After considering some of the advantages of Pd‐103 over I‐125, we designed a phase I‐II clinical trial to assess the feasibility of intraoperative Pd‐103 in unresectable carcinoma of the pancreas to study the related morbidity when combined with chemotherapy and external beam radiation, and to evaluate the impact on palliation and local control rates. Between December 1989 and December 1993, 15 patients with biopsy‐proven unresectable adenocarcinoma of the pancreas were treated with interstitial Pd‐103 implants during laparotomy. In 13 patients the lesion was located in the head of the pancreas, in one patient in the uncinate process, and in one patient in the body of the pancreas. The stage distribution was as follows: T1 = 2; T2 = 6, and T3 = 7. In addition, all patients underwent biliary and gastric bypass. The mean number of Pd‐103 pellets was 45; the mean total activity to obtain a matched peripheral dose (MPD) of 11,000 cGy was 68.9 mCi. The mean tumor volume encompassing the MPD was 16.5 cc. All patients received postoperative external beam radiation (4,500 cGy over 4 1/2 weeks) and chemotherapy (5‐fluorouracil and mitomycin C). This combined treatment, consisting of intraoperative brachytherapy using Pd‐103 and postoperative external beam radiation with chemotherapy, was well tolerated in all patients. There were no treatment‐related mortalities, and no serious complications, such as bleeding or fistula formation. Pain relief was obtained within 3–6 weeks in 10 out of 12 patients presenting with pain. Survival ranged from 6 to 24 months (median 10 months). The study suggests that Pd‐103 can be considered an alternative to I‐125 for interstitial brachytherapy for unresectable carcinoma of the pancreas. Symptom relief appeared to occur faster and complications are significantly less. However, this study did not show any improvement in the median survival rate over I‐125 due to the advanced stage cancer in the majority of patients in the study.

Esophageal Perforation After Gastric Balloon Extraction

We report a case of a 59-year-old female with esophageal perforation following endoscopic removal of an intragastric balloon. To our knowledge, this is the first case of esophageal perforation associated with intragastric balloon extraction reported in the English literature.

Cognitive changes after surgery in the elderly: does minimally invasive surgery influence the incidence of postoperative cognitive changes compared to open colon surgery?

Background: Postoperative delirium in the elderly is a growing concern. Data regarding significant differences in postoperative cognitive dysfunction (POCD) in elderly persons undergoing laparoscopic versus open colon resection are not well established. Objectives: The goal of this study was to compare the incidence of POCD in laparoscopic versus open colon surgery in an elderly population. Design and Setting: A prospective nonrandomized pilot study was conducted at an urban tertiary care hospital. Participants: The study included patients aged 65 years and above, without documented dementia who underwent elective colon surgery. Measurements: We collected demographic and clinical data, including age, sex, polypharmacy, and comorbidities. The subjects underwent pre- and postoperative Cambridge Neuropsychological Test Automated Battery (CANTAB) testing. Worsening individual scores from the Paired Associated Learning (PAL) and Spatial Working Memory (SWM) portions of CANTAB determined the presence of POCD. Inflammatory cytokine (i.e., IL-6) levels were measured pre- and postoperatively. Results: We enrolled 44 subjects (26 laparoscopic and 18 open surgery). The two groups did not differ significantly in age, sex, polypharmacy, and comorbidities. The average incidence of POCD was 47%. PAL scores worsened in 12/23 (52%) in the laparoscopic group and in 7/15 (47%) in the open group. These group differences lacked statistical significance (p = 0.75). SWM scores worsened in 14/25 (56%) in the laparoscopic group and in 6/18 (33%) in the open group, which was also not statistically significant (p = 0.12). No age difference occurred between the ‘worsened scores group and ‘stable scores group, and older age was not associated with POCD. IL-6 levels were higher in the open versus the laparoscopic group (p < 0.0001). Conclusion: In this pilot study, the average incidence of POCD was not statistically different between elderly subjects undergoing open versus laparoscopic surgery. Age did not influence the occurrence of POCD. Although inflammatory markers were significantly higher in the open group, consistent with a higher degree of stress response, this group did not have higher rates of delirium. This association is worth to be investigated in a larger sample.