Jean-Denis Yelle

Management of choledocholithiasis in the time of laparoscopic cholecystectomy

BACKGROUND The best way to detect and manage common duct stones in conjunction with laparoscopic cholecystectomy is not agreed upon at the present time. PATIENTS AND METHODS Our experience with choledocholithiasis in a consecutive series of 1,123 cholecystectomies (94% by laparoscopy) has been reviewed. Suspected duct stones were investigated preoperatively or postoperatively by endoscopic retrograde cholangiography (ERC), and if necessary, duct clearance was attempted by endoscopic sphincterotomy (ES). No attempt was made to identify choledocholithiasis intraoperatively. RESULTS Endoscopic retrograde cholangiography was performed in 11% of patients, and 32% of these required ES. The complication rate of ERC and ES was 8%, without mortality. Two patients required a second operation for missed choledocholithiasis, for a reoperation rate of 0.2%. CONCLUSION We believe that primary or secondary open surgery is only occasionally necessary for the management of choledocholithiasis. Preoperative ERC and ES for suspected duct stones, with the same strategy employed as a salvage for stones presenting after cholecystectomy, was safe and efficient.

Delay in operative stabilization of spine fractures in multitrauma patients without neurologic injuries: effects on outcomes

BACKGROUND Optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates mobilization and theoretically reduces associated complications. METHODS We identified consecutive patients without neurologic injury requiring stabilization surgery for a spinal fracture at an academic tertiary-care hospital over a 12-year period. Incidences of postoperative complications were prospectively evaluated. We analyzed results based on the time elapsed before the final surgical stabilization procedure. Multivariate analyses were performed to explore the effects of potential confounders. RESULTS A total of 83 patients (60 men, 23 women; mean age 39.4 yr) met the eligibility criteria and were enrolled. The mean Injury Severity Score (ISS) was 27.1 (range 12.0-57.0); 35% of patients had a cervical fracture and 65% had a thoraco-lumbar fracture. No statistically significant associations were uncovered between time to surgical stabilization and age, ISS or comorbidities. Comparing patients stabilized after 24 hours with those stabilized within 24 hours, there was an almost 8-fold greater risk of a complication related to prolonged recumbency (p = 0.007). We observed similar effects for other types of complications. Delays of more than 72 hours had a negative effect on complication rates; these effects remained significant after multivariate adjustments for age, comorbidity and ISS. CONCLUSION This study demonstrates a strong relation between timing of surgical stabilization of spinal fractures in multitrauma patients without neurologic injuries and complications. Further studies with larger samples may allow for better adjustment of potentially confounding factors and identify subgroups in which this effect is most pronounced.

National Survey of Canadian General Surgery Program Directors Regarding Focused Assessment With Sonography for Trauma

INTRODUCTION Focused assessment with sonography for trauma (FAST) is an important modality in the initial assessment of trauma patients. Information regarding the current status, availability, as well as educational and training processes in the use of FAST is limited. The purpose of this study was to survey Canadian general surgery residency program directors regarding FAST. METHODS A Web-based survey was developed to assess the availability and use of FAST, education and training, as well as the role of FAST in general surgery residency training programs across Canada. Two experts reviewed the survey for validity and reliability. The survey was then pilot tested by 2 general surgeons. RESULTS The survey response rate was 75.0% (12/16). FAST was available at all the institutions that responded. FAST was used 100% of the time in the initial assessment of the trauma patient. In all, 75.0% (9/12) respondents have no formal residency training in FAST, 91.7% (11/12) of respondents agreed or strongly agreed that training in FAST should be included in the residency curriculum, and 66.7% (8/12) of respondents perceive that general surgery residents are not competent in the use of FAST. CONCLUSIONS Overall, Canadian general surgery program directors do not feel that surgical residents are competent in the use of FAST. Current training is limited, and program directors believe that training and education in FAST should be included in the postgraduate education curriculum.