Jose M. Martinez

General surgery residency inadequately prepares trainees for fellowship: results of a survey of fellowship program directors.

Objective:To assess readiness of general surgery graduate trainees entering accredited surgical subspecialty fellowships in North America. Methods:A multidomain, global assessment survey designed by the Fellowship Council research committee was electronically sent to all subspecialty program directors. Respondents spanned minimally invasive surgery, bariatric, colorectal, hepatobiliary, and thoracic specialties. There were 46 quantitative questions distributed across 5 domains and 1 or more reflective qualitative questions/domains. Results:There was a 63% response rate (n = 91/145). Of respondent program directors, 21% felt that new fellows arrived unprepared for the operating room, 38% demonstrated lack of patient ownership, 30% could not independently perform a laparoscopic cholecystectomy, and 66% were deemed unable to operate for 30 unsupervised minutes of a major procedure. With regard to laparoscopic skills, 30% could not atraumatically manipulate tissue, 26% could not recognize anatomical planes, and 56% could not suture. Furthermore, 28% of fellows were not familiar with therapeutic options and 24% were unable to recognize early signs of complications. Finally, it was felt that the majority of new fellows were unable to conceive, design, and conduct research/academic projects. Thematic clustering of qualitative data revealed deficits in domains of operative autonomy, progressive responsibility, longitudinal follow-up, and scholarly focus after general surgery education.

Endoscopic retrograde cholangiopancreatography and gastroduodenoscopy after Roux-en-Y gastric bypass

BackgroundThe use of Roux-en-Y gastric bypass (RYGB) for morbid obesity has raised concern that subsequent endoscopic evaluation of the gastric remnant and duodenum is difficult. By gaining percutaneous access to the gastric remnant, however, both gastroduodenoscopy and endoscopic retrograde cholangiopancreatography (ERCP) can be performed easily. This report describes the results of a novel technique for performing “transgastrostomy” gastroduodenoscopy and ERCP.MethodsSix patients with a RYGB for morbid obesity underwent transgastric remnant endoscopic evaluations. If a gastric remnant tube had not been placed during prior surgery, one was placed percutaneously by an interventional radiologist. The tube tract then was dilated to either 20- or 24-Fr. At the time of endoscopy, the gastrostomy tube was removed and the skin anesthetized. Then either a pediatric duodenoscope (outer diameter, 7.5 mm) or a slim gastroscope (outer diameter, 5.9 mm) was inserted through the gastrostomy tube tract.ResultsPercutaneous gastroduodenoscopy was successfully performed for all six patients. The findings included two patients with prepyloric ulcers identified and assessed with a biopsy, one patient with intestinal metaplasia and a benign gastric polyp, and three patients with a normal gastric remnant and duodenum. A nonstrictured enteroenterostomy was noted in one of the three patients with a normal endoscopic evaluation. Percutaneous transgastrostomy ERCP was performed for three of the six patients who underwent gastroduodenoscopy. The findings included one patient who had papillary fibrosis treated with a sphincterotomy, a second patient with a normal biliary tree, and a third patient with a normal pancreatic duct. Selective cannulation of the common bile duct was not successful in the third patient.ConclusionThe transgastrostomy endoscopic route ensures access to the excluded stomach and proximal small bowel after RYGB. This route is safe and effective, allowing the use of a duodenoscope to improve the cannulation success rate for ERCPs in this patient population.

Late immunoneutralization of procalcitonin arrests the progression of lethal porcine sepsis.

BACKGROUND Procalcitonin (ProCT) is becoming increasingly recognized as a mediator as well as a marker of sepsis. Serum ProCT concentrations rise soon after induction of sepsis and remain elevated over a prolonged period of time. In contrast, many pro-inflammatory cytokines, e.g., tumor necrosis factor alpha (TNF-alpha) and interleukin-1 beta (IL-1beta), rise and decline early in the course of sepsis. Researchers have improved survival in animal models of sepsis by prophylactically blocking IL-1beta and TNF-alpha with immunotherapy, but therapeutic treatment has been less successful in clinical trials. We hypothesized that the sustained elevation of ProCT in the serum would allow for effective therapeutic immunoneutralization of this peptide late in the course of sepsis. METHODS Lethal polymicrobial sepsis was induced in 10 castrated, male Yorkshire pigs by intraabdominal spillage of cecal contents (1 gm/kg) and intraabdominal instillation of 2 x 10(11) cfu of a toxigenic strain of E. coli (O18:K1:H7). The treated group (n = 5) received an intravenous infusion of purified rabbit antiserum to the aminoterminus of porcine ProCT. The control group (n = 5) received nonreactive, purified rabbit IgG. The purified antiserum was infused to all animals 3 h after the induction of sepsis, at which time very severe physiologic dysfunction was manifest, and many of the animals appeared to be preterminal. Physiologic and metabolic parameters were measured until death or for 15 h after induction of sepsis, at which time all surviving animals were euthanized. RESULTS Therapeutic immunoneutralization of serum ProCT improved most measured physiologic and metabolic parameters in septic pigs. Specifically, there was a significant increase in mean arterial pressure, urine output and cardiac index in all animals treated with ProCT antibody. Serum creatinine was significantly lower in treated animals. Although acidosis was not as severe in treated animals, as indicated by higher pH values and lower lactate concentrations, these results did not achieve statistical significance. Significantly, 11 h after the induction of sepsis there was 100% mortality in the control group while only one animal in the treated group expired. CONCLUSION The prolonged elevation of ProCT concentrations in sepsis allows neutralization of this peptide to be effective during the course of this disorder. These findings suggest that immunoneutralization of ProCT may be a useful treatment in clinical situations where sepsis is already fully established.

Fundamentals of endoscopic surgery cognitive examination: Development and validity evidence

BackgroundFlexible endoscopy is an integral part of surgical care. Exposure to endoscopic procedures varies greatly in surgical training. The Society of American Gastrointestinal and Endoscopic Surgeons has developed the Fundamentals of Endoscopic Surgery (FES), which serves to teach and assess the fundamental knowledge and skills required to practice flexible endoscopy of the gastrointestinal tract. This report describes the validity evidence in the development of the FES cognitive examination.MethodsCore areas in the practice of gastrointestinal endoscopy were identified through facilitated expert focus groups to establish validity evidence for the test content. Test items then were developed based on the content areas. Prospective enrollment of participants at various levels of training and experience was used for beta testing. Two FES cognitive test versions then were developed based on beta testing data. The Angoff and contrasting group methods were used to determine the passing score. Validity evidence was established through correlation of experience level with examination score.ResultsA total of 220 test items were developed in accordance with the defined test blueprint and formulated into two versions of 120 questions each. The versions were administered randomly to 363 participants. The correlation between test scores and training level was high (r = 0.69), with similar results noted for contrasting groups based on endoscopic rotation and endoscopic procedural experience. Items then were selected for two test forms of 75 items each, and a passing score was established.ConclusionsThe FES cognitive examination is the first test with validity evidence to assess the basic knowledge needed to perform flexible endoscopy. Combined with the hands-on skills examination, this assessment tool is a key component for FES certification.

Endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass.

INTRODUCTION Roux-en-Y gastric bypass is an excellent option for weight loss in the morbidly obese. Unfortunately, some patients do have weight regain or insufficient weight loss. Revisional bariatric surgery is not without risk. Less invasive techniques may provide alternative treatments for patients that regain weight or have insufficient weight loss. This video demonstrates a technique of endoscopic sclerotherapy for dilated gastrojejunostomy after gastric bypass. METHODS The technique is applied to patients who have had weight regain or insufficient weight loss following gastric bypass. Patients who have lost the feeling of satiety, undergone reeducation and recounseling of dietary changes, and have documented dilated gastrojejunostomy on upper endoscopy and/or a barium study are offered this technique. If the gastojejunostomy is larger than 12 mm, sodium morrhuate is injected with an endoscopic needle circumferentially. RESULTS The gastrojejunostomy is injected with 6-30 cc of sodium morrhuate. By visual inspection, the anastomosis usually appears smaller after the procedure. Most patients report a subjective feeling of satiety after the endoscopic sclerotherapy. Reinjection after 3 months has been performed in some patients. Except mild nausea, the patients have experienced no morbidity or mortality from the procedure. CONCLUSIONS Endoscopic sclerotherapy may offer an alternative treatment for dilated gastrojejunostomy after gastric bypass. The technique described in the video is a relatively easy, safe method that may become the first line of therapy in patients who have a dilated gastrojejunostomy and have lost the feeling of satiety after gastric bypass with an associated weight gain.

Why fundamentals of endoscopic surgery (FES)

As flexible endoscopy has moved into the mainstream, gastroenterologists have embraced many of the skills and techniques particular to this modality of diagnosis and intervention. Their adoption of flexible endoscopic technology and training, and the lack of enthusiasm for endoscopic therapy potentials by surgeons, has left many surgical residents and practicing surgeons deficient in endoscopic skills. As a result, education of surgical residents in flexible endoscopy has lagged and training of surgical residents in flexible endoscopy is increasingly coming under scrutiny and has become an area of debate. The medical literature and practice guidelines are replete with articles from surgeons and gastroenterologists debating the appropriate education and training in flexible endoscopy. Both surgical and gastroenterology professional societies have published guidelines for training in flexible endoscopy. These guidelines are often at odds with each other, citing opposing literature supporting their position on appropriate criteria for training in basic upper and lower endoscopy [1–4]. Flexible endoscopy is a critical element of any general surgeon’s and colorectal surgeon’s practice. In 2007, 74 % of rural surgeons performed more than 50 flexible endoscopic procedures each year, with 42 % of rural surgeons performing more than 200 flexible endoscopic procedures annually [5]. In a 2010 report on rural, under-served areas that lack gastroenterology services, 39.8 % of an American general surgeons’ practice comprises flexible endoscopic procedures [6]. In Canada, surgeons were found to be the primary providers of flexible endoscopic services in smaller urban and rural areas [7]. The American Board of Surgery (ABS) has begun to address the training inequity that exists between general surgery residents and gastroenterology fellows [8]. In an effort to ensure surgical residents are fully trained and competent in flexible endoscopy, the ABS has not only increased the minimum requirements for training general surgery residents in flexible endoscopy but has also undertaken the task of formalizing a flexible endoscopy curriculum for its residents. Currently, the ABS and Residency Review Committee (RRC) recommend 35 upper endoscopic procedures and 50 colonoscopies as the minimum number of procedures to be performed by surgical residents. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the ABS have long espoused that numbers do not ensure competency in surgical or endoscopic procedures. This position is fully supported by data. In 2004, the SAGES esophagogastroduodenoscopy (EGD) Outcomes Study Group prospectively reviewed 3,525 EGDs performed by surgeons, showing a high degree of success with low morbidity. There was no correlation between experience (i.e. number of cases performed) and completion rates or major complications [9]. A similar trial by the SAGES Colonoscopy Study Outcomes Group prospectively reviewed 13,580 colonoscopies performed by surgeons and found no correlation between experience and complications, with an acceptable success rate. The investigators noted that a minimum of 50 colonoscopies with 100 performed annually showed a significant improvement in completion rates Taskforce Members are listed in Appendix.

Use of biologic mesh for a complicated paracolostomy hernia

BACKGROUND Parastomal hernias are among the most frustrating and incapacitating complications of permanent colostomies. Because the traditional surgical options of primary repair with or without ostomy repositioning have led to disappointing results, the use of mesh is indicated, especially in the setting of multiple recurrences. METHODS After laparoscopic lyses of adhesions, the colostomy is pushed against the lateral abdominal wall, and a bovine pericardium graft is gently stretched and draped over the colostomy (the Sugarbaker technique). Transfascial sutures and tacks are placed along the perimeter of the mesh and around the colon to prevent small bowel herniation. RESULTS The patient developed a small seroma postoperatively, which resolved spontaneously. At his 17-month follow-up, the patient had no evidence of recurrence, he was pain free, and he was satisfied with his cosmetic results. CONCLUSION Although several studies indicate the feasibility and efficacy of synthetic permanent mesh repair, the concerns of mesh infection, erosion, and ostomy obstruction still persist. The authors suggest parietalizing the bowel and using a biologic mesh.

The double-wire technique as an aid to selective cannulation of the common bile duct during pediatric endoscopic retrograde cholangiopancreatography

Background: Selective cannulation of the common bile duct (CBD) during endoscopic retrograde cholangiopancreatography (ERCP) can be difficult. Several techniques have been described to assist endoscopists in obtaining access when initial cannulation fails. The objective of this report is to describe our initial experience with the “double-wire technique” in the pediatric population. Patients and Methods: Sixty ERCPs were performed in children with ages ranging from 8 months to 18 years and the technique was used in 8 cases. After wire-guided access to the pancreatic duct is obtained, the wire is left in place within the pancreatic duct to aid subsequent selective cannulation of the CBD. Results: In 2 of these cases, transient increase in pancreatic enzymes was observed after ERCP. Nevertheless, in this small series of patients it was found to be an effective and useful tool in cases in which repeated attempts have yielded only pancreatic duct cannulation. Conclusions: This technique is a useful aid for the endoscopist attempting to selectively cannulate the CBD in difficult cases. Further study will be needed to establish the safety of this technique in the pediatric population.

Technical Modification for Laparoscopic Donor Nephrectomy to Minimize Testicular Pain: A Complication with Significant Morbidity

The laparoscopic approach to donor nephrectomy is becoming increasingly common. While it is felt that the recovery from laparoscopic nephrectomy is quicker and less painful, a number of complications have been reported. A rarely reported on complication in the literature with significant morbidity is ipsilateral orchalgia. From 1998 to 2008, 257 hand‐assisted laparoscopic donor nephrectomies were performed at our institution. Eight of 129 (6.2%) men complained of de novo ipsilateral orchalgia postoperatively. The average duration of pain was 402 days. Patients reported significant morbidity related to this complication. None, however, required further treatment. Three patients reported that they would reconsider organ donation as a result of testicular pain. Our technique originally included dissection and ligation of the gonadal vein en bloc with the ureter at the level of the left common iliac artery. Since recognizing this complication, we have adopted a gonadal vein sparing approach so as not to disturb the vessel below its point of ligation at the renal vein. To date, 50 patients have undergone the modified technique without experiencing orchalgia. In conclusion, ipsilateral testicular pan is a relatively frequent complication of laparoscopic donor nephrectomy and may be a source of significant morbidity. Using a modified surgical technique, this complication can be reduced or eradicated.

Technical Skills Rotation for General Surgery Residents1

BACKGROUND Technical skills are an important part of any general surgery residency curriculum. With the demands of limited work weeks, it is imperative that educators create novel methods of teaching technical skills to their residents. Our program utilizes a dedicated month to help accomplish this. This study hypothesized that general surgery residents would report a positive effect of a dedicated technical skills rotation. METHODS Residents who had undergone a 1 mo rotation in technical skills during their first year were asked to fill out a survey concerning their experience. During the 1-mo rotation, the residents had almost no clinical responsibilities. Teaching of technical skills was performed with various activities, including video content (VC), virtual reality simulators (VR), open foam procedures (OF), laparoscopic box trainers (BT), surgical equipment in-service (SE), and animate sessions (AS). Responses were given on a Likert scale (1-10) with higher numbers being more positive responses. RESULTS There were seven residents in this study. The residents gave a very positive response to the overall rotation (9.4) and exposure to laparoscopic procedures (9.6). The other responses were enthusiastic as well: exposure to open procedures (8.9) and preparation for operative room (9.4). After their rotation, the residents were comfortable performing a laparoscopic cholecystectomy (9.2), a hand-sewn anastomosis (8.7), and a stapled anastomosis (9.4). The residents found theses activities helpful in increasing order: VC (7.8), VR (8.0), BT (9.0), ES (9.7), OF (9.8), and AS (9.8). CONCLUSIONS A 1-mo dedicated technical skills rotations was perceived to be extremely positive by the residents. The residents felt very comfortable performing a laparoscopic cholecystectomy, a hand-sewn anastomosis, and a stapled anastomosis. With the 80-h work week, alternatives to learning technical skills in the operating room are essential. Further studies need to be performed to determine if this rotation aids in accomplishing this goal.