Jonathan L. Pierce

Higher surgical wound complication rates with sirolimus immunosuppression after kidney transplantation: A matched-pair pilot study

Sirolimus, a potent new immunosuppressant, has been anecdotally associated with surgical wound complications. We studied postoperative surgical wound complications in 15 kidney recipients receiving sirolimus, prednisone, and tacrolimus or cyclosporine (study group) compared with 15 recipients receiving tacrolimus, prednisone, and mycophenolate mofetil who were pair-matched for surgical wound complication risk factors. Surgical wound complications were defined as any complication related to the surgical transplant wound requiring reintervention. Fifty-three percent of the study group and 7% of the control group experienced more than one surgical wound complication (P =0.014), and the relaparotomy incidence was 33% and 7%, respectively. Four graft losses have occurred since the beginning of the study: one chronic rejection and two deaths with function in the study group, and one death with function in the control group. At 1 year, graft survival for study recipients compared with control recipients was 87% and 93%, respectively; patient survival was 93% in both groups. Recipients receiving sirolimus demonstrated a significantly higher surgical wound complication rate, but graft and patient survival were not affected. Peritransplant immunosuppression with sirolimus and steroids warrants careful consideration, particularly in recipients with surgical complication risk factors.

The utility of routine postoperative upper GI series following laparoscopic gastric bypass

BackgroundRoutine upper gastrointestinal (UGI) studies following laparoscopic Roux-en-Y gastric bypass (LRYGBP) have the potential advantage of early identification of anastomotic complications. The aim of our study was to evaluate the efficacy of routine postoperative UGI and its relationship to clinical outcomes.MethodsOver a three-year period, 516 patients underwent LRYGBP followed by routine postoperative UGI studies. Data were collected on the results of the UGI, clinical parameters, and patient outcomes. Study groups were composed of patients with a normal UGI (Group I, n = 455), abnormal UGI not requiring further intervention (Group II, n = 36), and abnormal UGI requiring further intervention (Group III, n =25). Statistical significance was set at α= 0.05 level for all analyses.ResultsThe three study groups were not statistically different in mean age (42 years) or body mass index (BMI) (45) and were predominantly female (90%). Most patients had an uneventful postoperative course. Anastomotic complications (gastrojejunostomy and jejunojejunostomy) were uncommon (1.3%). The sensitivity of the UGI for anastomotic leak in this study was low (33%). However, all patients with alimentary limb obstruction (n = 3) had UGI evidence of this complication. Of the 516 UGI reports, there were only 25 (4.8%, Group III) that were abnormal and required some form of intervention ranging from serial imaging (84%) to reoperation (16%). Of the various clinical parameters examined, the patients in Group III demonstrated a significantly higher prevalence of fever (p < 0.001), tachycardia (p < 0.01), vomiting (p < 0.001), and postoperative day 1 leukocytosis (p < 0.005).ConclusionsOur data suggest that routine UGI after LRYGBP has limited utility as it may result in unnecessary intervention based on false-positive results or a delay in treatment based on false-negative results. We advocate selective UGI imaging following LRYGBP based on the patient’s clinical factors, particularly fever and tachycardia.

Calcific myonecrosis mimicking an invasive soft-tissue neoplasm. A case report and review of the literature.

Calcific myonecrosis has been reported as a late sequela of compartment syndrome, injury to the common peroneal nerve, and injury to the lower extremity without documented compartment syndrome or neurological injury1-8,13-19. This rare condition has been reported to occur ten to sixty-four years after the initial injury and typically presents as an enlarging mass in the anterior compartment of the leg. The characteristic radiographic appearance is that of a large fusiform soft-tissue mass in the anterior compartment, with peripheral plaque-like calcifications and usually with a well defined border. The calcifications may extend along fascial planes13. Erosion of bone had been reported in only four patients8,13. The benign radiographic appearance usually allows the lesion to be differentiated from an enlarging malignant mass in the soft tissues7. A sterile abscess usually is found at the time of operative treatment, but there is a high prevalence of chronic draining sinuses and secondary infection3,7,8,18. We report the case of a patient who was seen because of a painless, enlarging mass in the anterior and lateral compartments of the leg thirty years after he had been hit by an automobile. At the time of the initial injury, he had sustained damage to the knee, a partial sciatic-nerve palsy, and a probable compartment syndrome of the leg. The case of our patient differs substantially from previously reported cases of calcific myonecrosis in that there was extensive erosion of bone, giving the lesion the appearance of an invasive neoplasm. A forty-nine-year-old man was referred for evaluation of a slowly enlarging mass in the right leg. Thirty years previously, he had been struck by an automobile while walking. He stated that he had sustained …

3-D Telestration: A Teaching Tool for Robotic Surgery

BACKGROUND Telestration is an important teaching tool in minimally invasive surgery (MIS). While robotic surgery offers the added benefit of three-dimensional (3-D) visualization, telestration technology does not currently exist for this modality. This project aimed to develop a video algorithm to accurately translate a mentors two-dimensional (2-D) telestration into a 3-D telestration in the da Vinci visual field. MATERIALS AND METHODS A prototype 3-D telestration system was constructed to translate 2-D telestration from a mentor station into 3-D graphics for the trainee at the robotic console. This system uses fast image correlation algorithms to allow 2-D images to be placed over the same anatomic location in the two separate video channels of the stereoscopic robotic visualization system. Three subjects of varying surgical backgrounds, blinded to the mode of telestration (2-D vs. 3-D), were tested in the laboratory, using a simulated robotic task. RESULTS There were few technologic errors (2), only one of which resulted in a task error, in 99 total trials. Only the experienced MIS staff surgeon had a significantly faster task time in 2-D than in 3-D (P < 0.05). The MIS fellow recorded the fastest task times in 2-D and 3-D (P < 0.05). There were nine task errors, six of which were committed by the MIS fellow. The nonsurgeon trainee had the least number of errors but also had the slowest times. CONCLUSIONS Robotic telestration in 3-D is feasible and does not negatively impact performance in laboratory tasks. We plan to refine the prototype and investigate its use in vivo.

The surgical residency baby boom: changing patterns of childbearing during residency over a 30-year span.

BACKGROUND Birthrates during surgical residency appear to be rising. One assumption is that this is due to changes in the structure of surgical residencies. OBJECTIVE The purpose of our study was to explore whether an increase in birthrates has occurred and the reasons for this. METHODS We conducted an anonymous survey of current residents and alumni from 1976 to 2009 at a single university-based surgery training program. RESULTS Alumni (46 of 116) and current residents (38 of 51) were surveyed, and our response rate was approximately 50% (84 of 167). Respondents were grouped into cohorts based on their residency start year. The early cohort consisted of residents starting residency between 1976 and 1999, and the late cohort consisted of residents starting residency between 2000 and 2009. The percentage of male residents with children during residency training was similar for the early and late cohorts (34% [10 of 29] versus 41% [9 of 22]). For female residents, there was a substantial increase in childbearing for the late cohort (7% [1 of 15] versus 35% [6 of 18]). Fifty-two percent (44 of 84) of the respondents who had children during residency reported that work hours and schedule had a negative effect on their decision to have children. Most respondents reported that availability or cost of child care, impact on residency, support from the program, increased length of training, or availability of family leave did not factor as concerns. CONCLUSIONS Childbearing during residency has increased in female residents in our study. Surgical residency programs may need to accommodate this change if they want to continue to recruit and retain talented residents.

Bariatric Surgery and the Changing Current Scope of General Surgery Practice Implications for General Surgery Residency Training

IMPORTANCE The scope of general surgery practice has evolved tremendously in the last 20 years. However, clinical experience in general surgery residency training has undergone relatively little change. OBJECTIVE To evaluate the current scope of academic general surgery and its implications on surgical residency. DESIGN, SETTING, AND PARTICIPANTS The University HealthSystem Consortium and Association of American Medical Colleges established the Faculty Practice Solution Center (FPSC) to characterize physician productivity. The FPSC is a benchmarking tool for academic medical centers created from revenue data collected from more than 90,000 physicians who practice at 95 institutions across the United States. MAIN OUTCOMES AND MEASURES The FPSC database was queried to evaluate the annual mean procedure frequency per surgeon (PFS) in each calendar year from 2006 through 2011. The associated work relative value units (wRVUs) were also examined to measure physician effort and skill. RESULTS During the 6-year period, 146 distinct Current Procedural Terminology codes were among the top 100 procedures, and 16 of these procedures ranked in the top 10 procedures in at least 1 year. The top 10 procedures accounted for more than half (range, 52.5%-57.2%) of the total 100 PFS evaluated for each year. Laparoscopic Roux-en-Y gastric bypass was consistently among the top 10 procedures in each year (PFS, 18.2-24.6). The other most frequently performed procedures included laparoscopic cholecystectomy (PFS, 30.3-43.5), upper gastrointestinal tract endoscopy (PFS, 26.5-34.3), mastectomy (PFS, 16.5-35.0), inguinal hernia repair (PFS, 15.5-22.1), and abdominal wall hernia repair (PFS, 21.6-26.1). In all years, laparoscopic Roux-en-Y gastric bypass generated the highest number of wRVUs (wRVUs, 491.0-618.2), and laparoscopic cholecystectomy was regularly the next highest (wRVUs, 335.8-498.7). CONCLUSIONS AND RELEVANCE A significant proportion of academic general surgery is composed of bariatric surgery, yet surgical training does not sufficiently emphasize the necessary exposure to technical expertise and clinical management of the patient undergoing bariatric surgery. As the scope of general surgery practice continues to evolve, general surgery residency training will need to better integrate the exposure to bariatric surgery.

Laparoscopic Transdiaphragmatic Pericardial Window: Getting to the Heart of the Matter

BACKGROUND Penetrating wounds to the upper abdomen and lower precordium mandate exclusion of intra-abdominal and cardiac injuries. The most sensitive test to exclude cardiac injury is direct visualization of the pericardial fluid. Since 2001, we have examined the abdomen and performed transdiaphragmatic (central tendon) pericardial window via laparoscopy in stable patients at risk for both cardiac and peritoneal injuries. STUDY DESIGN At our Level I trauma center we reviewed consecutive patients who underwent evaluation of pericardial fluid after trauma between 2001 and 2008 and identified those patients in whom laparoscopic pericardial window was performed. We collected data on demographics, technique, findings, complications, and follow-up. RESULTS There were 393 patients who underwent diagnostic laparoscopy. Of those, 38 patients received laparoscopic transdiaphragmatic pericardial window. Six cardiac injuries (15.8%) were identified with 5 penetrating injuries to the right ventricle and 1 myocardial contusion. All 5 right ventricular injuries required median sternotomy for injury repair. None of the patients had significant hemodynamic compromise during operation. The pericardial window was left open in all patients, with no morbidity. The average length of stay for patients without chest tubes and a negative window was less than 24 hours. For patients with chest tubes, length of stay was 4.6 days. The interquartile range for follow-up was 21.5 to 315 days. CONCLUSIONS Diagnostic laparoscopy with transdiaphragmatic pericardial window allows for thorough evaluation of both abdominal and cardiac injuries with a resultant short length of stay and no morbidity or mortality. In this, the largest series in the literature, laparoscopic pericardial window was a safe and effective modality to evaluate hemodynamically stable patients who are at risk for both cardiac and abdominal injuries.

Impact of laparoscopic nephrectomy on donor preoperative decision-making and postoperative quality of life and psychosocial outcomes

Sirs, We read with great interest the study by Neuhaus et al. reporting on live kidney donors (that had donated by open nephrectomy) and their high degree of satisfaction with the predonation decision-making process, along with improved postdonation relationships with their partners and the recipient children [1]. One question that this valuable and insightful study was unable to answer was whether the recent introduction of the less invasive laparoscopic technique (which has rapidly become the standard of care) [2, 3] has had any additional effects on the decision-making process and postoperative family dynamics and quality of life of those donating a kidney to a pediatric recipient. Interestingly, in adult-toadult live donor kidney transplantation, several studies have demonstrated that laparoscopic live donor nephrectomy does not only significantly decrease postoperative morbidity [4], but may therefore also have contributed to the steady increase of live donor kidney transplants observed in recent years [5–7]. Pradel et al. reported that this new, less morbid technique may also have impacted live donation rates positively by increasing the willingness of adult kidney recipients to accept a kidney from a live donor [8]. In a retrospective pilot study, we surveyed the 29 donors of 29 consecutive pediatric (≤18 years old) recipients at our center. All donors were mailed an SF-36 health questionnaire [9] and a structured questionnaire regarding preoperative decision-making, postoperative recovery, family dynamics, and quality of life. We analyzed categorical variables by use of the Chi-square test and, when applicable, Fishers Exact Test, and continuous variables by use of the Mann-Whitney U test. For all statistical tests, a p value of less than 0.05 was considered significant. Of the 29 adult donors, 14 were laparoscopic donors (04/97–06/02) and 15 open donors (12/91–03/97) (median age, 34 years vs. 31 years; p=n.s.). There were no significant differences in SF-36 responses between laparoscopic donors, open donors, and a normative sample of the general US population. For preoperative variables, we received responses from 11 (79%) laparoscopic and 9 (60%) open donors; for postoperative variables, we received responses from 10 laparoscopic (71%) and 9 (60%) open donors. Ninety-five percent of the responding donors were a biologic or adoptive parent of the recipient. Median recipient age of laparoscopic and open donor kidneys was 9 and 12 years (range, 1 to 17 years for both groups; p=n.s.), respectively. One hundred percent of laparoscopic donors vs. 33% of open donors were working fullor part-time at the time of their donor operation. All but one donor in each group made the decision to donate immediately after hearing for the first time about live donation. One hundred percent of laparoscopic donors stated that the availability of the laparoscopic technique had not affected their decision to donate. For laparoscopic (vs. open) donors, median postoperative length of stay was significantly shorter (3 days vs. 5 days, respectively; p=0.02). Upon returning home, 80% of laparoscopic vs. 66% of open donors had to provide their care for themselves (p=n. s.). At that time, the primary caregiver for the recipient was the donor in 20% of all cases (laparoscopic and open donors), whereas at one month, the rate of the donor being the principal recipient caregiver had increased to 60% in the laparoscopic vs. 50% in the open group (p=n.s.). We noted a trend towards faster early postoperative reconvalescence for laparoscopic (vs. open) donors (p=n.s.; Table 1). At one month, 60% of laparoscopic vs. 11% of C. Troppmann (*) . J. L. Pierce . J. P. McVicar . R. V. Perez Department of Surgery, University of California, Davis, Medical Center, 2315 Stockton Blvd., HSF 2010, Sacramento, CA 95817, USA e-mail: christoph.troppmann@ucdmc.ucdavis.edu Tel.: +1-916-7347267 Fax: +1-916-7346564