Linda P. Zhang

Risk factors for the development of fulminant Clostridium difficile colitis.

BACKGROUND The development of fulminant Clostridium difficile colitis (FCDC) requires prompt operative intervention and is associated with a high mortality rate. The aim of this study was to use a case-control design to define the clinical and laboratory parameters that predict which patients with Clostridium difficile infection are most likely to progress to FCDC. METHODS Cases from 1994 to 2006 with documented in-hospital progression of Clostridium difficile infection to FCDC were matched retrospectively at the start of medical therapy by age, sex, and intensive care unit (ICU) status to controls with Clostridium difficile infection who did not develop FCDC. Chi-Square and multivariable logistic regression were used to identify risk factors for progression to FCDC. RESULTS A total of 35 patients with FCDC were matched to 70 controls with Clostridium difficile infection who did not develop FCDC. The patients with FCDC underwent colectomy after an average of 4.6 days of medical therapy and had a mortality rate of 40%. On multivariate analysis, independent risk factors for the development of FCDC were a WBC > 16,000 cells/mm(3) (P < .01) at initiation of therapy, operative therapy within the last 30 days (P = .03), a history of inflammatory bowel disease (P = .04), and a history of intravenous immunoglobulin treatment (P < .01). CONCLUSIONS Leukocytosis, recent prior operative therapy, and a history of inflammatory bowel disease and intravenous immunoglobulin treatment were negative prognostic indicators for patients with Clostridium difficile infection. The presence of these factors merits close observation for progression to FCDC and acceleration of the planning process for operative intervention.

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

BACKGROUND Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. STUDY DESIGN Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. RESULTS Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). CONCLUSIONS Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Laparoscopic gastrojejunostomy for the treatment of gastric outlet obstruction.

These authors found that laparoscopic gastrojejunostomy for the management of gastric outlet obstruction can be performed with good outcomes and acceptable complication rates.

The Effect of a Global Surgery Resident Rotation on Physician Practices Following Residency: The Mount Sinai Experience

OBJECTIVE The goal of the study was to evaluate the impact of Mount Sinais international rotation on physician practices and attitudes following residency. DESIGN An anonymous, retrospective study was conducted using an email survey. The initial survey was sent out in July 2015 with a second opportunity in September 2015. SETTING Mount Sinai Hospital, New York City. PARTICIPANTS All 62 graduates of the Mount Sinai General and Plastic Surgery residencies who participated in the international rotation over the last 10 years. RESULTS The primary outcome was level of involvement in service medicine with a secondary outcome examining participants views on the value of international rotations during residency. The response rate for the survey was 71% (44/62). Since leaving residency, 53% have been involved in one or more types of service medicine, 59% have been involved in at least one experience practicing medicine in an underserved area and 45% state that their current practice incorporates global surgery or service. 61% report that the rotation encouraged an interest in practicing in an underserved area and 44% (8/18) of those with no prior interest in global health reported that the rotation encouraged an interest. Respondents generally believe global health work could be rewarding (89%), provide opportunity for professional development (77%), and that residency should include global health electives (93%). CONCLUSIONS Our results suggest that a mandatory global health rotation may encourage an interest in service medicine. Thus, program directors should continue to provide and encourage participation in international rotations during surgical residency.

Transabdominal Nissen Fundoplication

Nissen fundoplication is offered to patients who have gastroesophageal reflux disease (GERD) refractory to maximal medical management. The open transabdominal Nissen fundoplication which is an effective elective anti-reflux procedure has now been replaced by its laparoscopic counterpart. This chapter lists the indications, essential steps, common technical variations, and complications of the procedure. It provides a detailed operative dictation template.