Karen R. Borman

General surgery workloads and practice patterns in the United States, 2007 to 2009: a 10-year update from the American Board of Surgery.

Objective:To assess changes in general surgery workloads and practice patterns in the past decade. Background:Nearly 80% of graduating general surgery residents pursue additional training in a surgical subspecialty. This has resulted in a shortage of general surgeons, especially in rural areas. The purpose of this study is to characterize the workloads and practice patterns of general surgeons versus certified surgical subspecialists and to compare these data with those from a previous decade. Methods:The surgical operative logs of 4968 individuals recertifying in surgery 2007 to 2009 were reviewed. Data from 3362 (68%) certified only in Surgery (GS) were compared with 1606 (32%) with additional American Board of Medical Specialties certificates (GS+). Data from GS surgeons were also compared with data from GS surgeons recertifying 1995 to 1997. Independent variables were compared using factorial ANOVA. Results:GS surgeons performed a mean of 533 ± 365 procedures annually. Women GS performed far more breast operations and fewer abdomen, alimentary tract and laparoscopic procedures compared to men GS (P < 0.001). GS surgeons recertifying at 10 years performed more abdominal, alimentary tract and laparoscopic procedures compared to those recertifying at 20 or 30 years (P < 0.001). Rural GS surgeons performed far more endoscopic procedures and fewer abdominal, alimentary tract, and laparoscopic procedures than urban counterparts (P < 0.001). The United States medical school graduates had similar workloads and distribution of operations to international medical graduates. Compared to 1995 to 1997, GS surgeons from 2007 to 2009 performed more procedures, especially endoscopic and laparoscopic. GS+ surgeons performed 15% to 33% of all general surgery procedures. Conclusions:GS practice patterns are heterogeneous; gender, age, and practice setting significantly affect operative caseloads. A substantial portion of general surgery procedures currently are performed by GS+ surgeons, whereas GS surgeons continue to perform considerable numbers of specialty operations. Reduced general surgery operative experience in GS+ residencies may negatively impact access to general surgical care. Similarly, narrowing GS residency operative experience may impair specialty operation access.

Civilian arterial trauma of the upper extremity. An 11 year experience in 267 patients.

Two hundred ninety-eight arterial injuries in 269 upper extremities were reviewed. Penetrating agents accounted for 250 injuries (93 percent) and blunt trauma for 19 (7 percent). Fifty-nine axillary, 126 brachial, 65 radial, and 48 ulnar arteries were damaged. Twenty-six extremities had more than one artery injured. The initial vascular examination revealed no abnormalities or was equivocal in 16 percent of all patients and in 32 percent of those with axillary artery injuries. Adjacent upper extremity structures were injured in 195 limbs (73 percent). Resection and primary anastomosis (54 percent) or vein interposition grafting (26 percent) were the most frequent methods of repair. Two deaths (0.7 percent) occurred and four amputations (1.5 percent) were required. Distal pulses were present at discharge in 93 percent of the evaluable extremities. Despite excellent success with arterial reconstruction, functional results were limited by associated nerve injuries. One hundred fifty patients (49 percent) had nerve deficits at discharge, and 71 (27 percent) had serious functional limitations.

Occult fever in surgical intensive care unit patients is seldom caused by sinusitis

Febrile intensive care unit (ICU) patients were evaluated prospectively for sinusitis. Of 598 admissions, 26 patients with transnasal cannulas, ICU stays over 48 hours, and occult fevers were identified. These 26 underwent physical examinations and sinus computed tomographic (CT) scans. Maxillary centeses and cultures were done in patients with CT abnormalities. Patients with positive scans had nasal tubes removed and received decongestants. Scans were abnormal in 19 (73%). All patients with major CT changes had positive maxillary taps. Most infections were polymicrobial; enteric bacilli were common. Fever resolved with nonoperative care in 18 (95%) patients; in only 1 patient was fever primarily from sinusitis. Sinus CT scans are often abnormal in ICU patients with occult fevers and transnasal cannulas. Pneumatic otoscopy can serve as a screening tool. Most patients respond to nonoperative management. Remote infections are often present. Although radiographic nosocomial ICU sinusitis is common, it is seldom the sole source of fever or the proximate cause of significant morbidity.

Treatment priorities in combined blunt abdominal and aortic trauma

Sixteen patients with blunt thoracic aortic transections also had intraabdominal injuries. Eleven patients had laparotomies first, and 5 patients had thoracotomies first. Records for the 16 patients were reviewed to identify successful treatment priorities. Active intraabdominal bleeding with present in 12 (75 percent) of the 16 patients. Bleeding was present in nine patients (82 percent) who underwent laparotomy first and in three patients (60 percent) who underwent thoracotomy first. Persistent or recurrent hypotension was associated with intraabdominal bleeding in eight patients. All patients had contained aortic hematomas and had successful repairs. Excluding early mortality related to associated injuries, the survival for patients who had laparotomy first was 63 percent and for patients who had thoracotomy first 60 percent. Laparotomy should be performed first in hypotensive patients with thoracic aortic transection and intraabdominal injury. The cause of hypotension is intraabdominal rather than aortic. In our study, delayed thoracotomy did not result in free rupture of the aortic hematoma.

Complement and the Severity of Pulmonary Failure

Complement-induced granulocyte aggregation is suspected as a cause of the adult respiratory distress syndrome. Quantifying the lung damage in these patients is difficult, and complement levels combined with clinical parameters of oxygenation might help define the severity of pulmonary deterioration. Forty-five high-risk patients, selected by arterial blood gas criteria, had their pulmonary insult related to C3a and C5a levels. Patients were stratified by pulmonary shunt, alveolar-arterial oxygen gradient, and radiographic findings into two categories of severity: pulmonary dysfunction, a milder insult, and ARDS, a major aberration in pulmonary function. The clinical assignment of a diagnostic category required at least 96 hours of monitoring. During this 96-hour period, multiple complement levels were obtained. These complement levels were then compared in pulmonary dysfunction and ARDS patients. ARDS patients had significantly higher C3a and C5a values after the patients were selected as high risk. These results suggest that the amount of complement activated in patients with incipient respiratory failure correlates with the severity of eventual pulmonary insult. The use of arterial blood gases and C3a and C5a levels should allow better and earlier definition of patients at risk for ARDS.

A decade of lower extremity venous trauma: Patency and outcome

Eighty-two patients with infrailiac venous injuries were reviewed. Veins were repaired in 75 patients and ligated in 7 patients. Clinical outcome could be correlated with anatomic patency for 41 patients who had postoperative venograms. Sixty-three percent of the repairs proved to be patent. Simple repairs were successful more often than complex ones. Site of injury and perioperative therapeutic adjuncts did not affect results. Eleven limbs were amputated, none solely because of venous injury. Edema was present at last follow-up in fewer patients with patent repairs than occluded repairs or ligations. Repair of major lower extremity venous injuries should be attempted routinely in stable patients. Improved patency of complex repairs may require increased use of balloon catheter thrombectomy and other adjunctive procedures. Postoperative venography is very useful for the evaluation of results.

Renal autotransplantation after horseshoe kidney injury: A case report and literature review

We present a patient with lap seatbelt trauma to a previously unsuspected horseshoe kidney. Preoperative single film intravenous pyelography did not suggest the presence of this renal anomaly or define the extent of renal injury. Because of the severity of the injury, nephrectomy was life-saving, but inadvertently rendered the patient anephric. Recognition of horseshoe kidney anatomy, microvascular back-bench reconstruction, and renal autotransplantation allowed the salvage of both the patient and her renal function.

Motivations to Pursue Fellowships Are Gender Neutral

OBJECTIVEnTo determine the importance of factors in decision making by general surgery chief residents to pursue fellowships and to relate factor importance to gender and residency characteristics.nnnDESIGNnProspective, voluntary, national survey conducted April through May, 2008, in which finishing chief residents rated the importance of 12 factors in their decision making to pursue fellowships.nnnSETTINGnGeneral surgery chief residents who applied for admission to the American Board of Surgery Qualifying Examination process.nnnPARTICIPANTSnAll 1034 first-time applicants.nnnMAIN OUTCOME MEASURESnchi(2) tests and 1-way analyses of variance were used to correlate gender and residency type, size, and location with summed values and scaled mean scores for ratings of the importance of 12 potential factors in fellowship decision making.nnnRESULTSnThe fellowship rate was 77% and correlated with residency size and location. Women were dispersed asymmetrically across residencies overall but future female fellows were distributed similarly to male ones. Survey item response rates for future fellows were 96% to 98%. Clinical mastery and specialty activities were valued most highly by more than 90% of men and women. Men placed more value on income potential and spousal influence. Lifestyle factors reached only midrange importance for both genders. Program size had more significant relationships to decision-making factors than did gender.nnnCONCLUSIONSnThe ability to master an area of clinical practice and the clinical activities of a specialty are the most important factors for chief residents in fellowship decision making, regardless of gender. Lifestyle factors are of midrange importance. Program size is as influential as is gender.

Guidelines for weaning from positive end-expiratory pressure in ventilated patients

Positive end-expiratory pressure is helpful in avoiding hypoxemia but can cause barotrauma to the lungs and heart. Reducing positive end-expiratory pressure as quickly as possible without sacrificing oxygenation is desirable. Weaning from positive end-expiratory pressure is an integral part of removing mechanical ventilation, but the selection of patients for positive end-expiratory pressure reduction and appropriate monitoring after this has not been established. We prospectively studied 29 positive end-expiratory pressure weaning trials to document oxygenation changes. Patients had stable vital signs and were not septic. All were receiving inspired oxygen concentrations of 50 percent or less and 5 to 12 cm H2O of positive end-expiratory pressure. Positive end-expiratory pressure was decreased by 2 cm H2O increments. Arterial blood gas levels were monitored at 1, 3, 5, and 30 minutes and at 1, 2, 4, and 6 hours after positive end-expiratory pressure reduction. Positive end-expiratory pressure reduction was successful if the partial pressure of oxygen value did not decrease below 65 mm Hg. Patients were successfully weaned from positive end-expiratory pressure in 27 of 29 trials (93 percent). The partial pressure of oxygen nadir occurred at 30 minutes. In successful trials, the partial pressure of oxygen value decreased an average of 12 mm Hg, an average change of -8 percent from the baseline partial pressure of oxygen value. This returned to baseline within 6 hours in only 13 patients (48 percent). The two patients in whom weaning failed had clinical signs of hypoxemia at 30 minutes. Their changes in partial pressure of oxygen at 30 minutes averaged -44 mm Hg (a 41 percent decrease). These data outline an approach to positive end-expiratory pressure weaning which is easy and practical. It supports oxygenation with the least physiologic embarrassment to the patient. In our patients it was 100 percent predictive of success.