Mark L. Friedell

Perceptions of Graduating General Surgery Chief Residents: Are They Confident in Their Training?

BACKGROUND Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

Surgery for carotid artery stenosis following neck irradiation

Carotid angioplasty and stenting (CAS) is being promoted for patients with carotid artery stenosis who have received neck irradiation. We reviewed our experience with carotid endarterectomy (CEA) following neck irradiation to determine if indeed postoperative and long-term problems were an issue in these patients. Over the past 13 years, 10 patients with a history of neck irradiation underwent 11 procedures. The average time interval between radiation treatment and surgery was 14 years (range 1-44). All carotid arteries were repaired with a standard endarterectomy, eight of which were patched. Three patients had undergone a radical neck dissection on the side ipsilateral to the carotid lesion. They received a pectoral myocutaneous flap (PMF) to protect the carotid artery and optimize wound healing. The lack of perioperative complications and of morbidity indicate that carotid reconstruction for patients with previous neck irradiation is safe and durable. Until long-term favorable results with CAS are available for these patients, operative intervention should remain the standard treatment.

Use of ultrasonic venography in the evaluation of venous valve function

Forty healthy limbs and 31 limbs with suspected deep venous insufficiency were imaged with real-time B-mode ultrasound to determine valve location, anatomic characteristics, and function. Valve function was evaluated by comparison with Doppler ultrasonographic techniques, and the data clearly indicated that ultrasonic venography accurately localized and determined the extent of deep venous reflux. Ascending contrast venography was performed in 15 postphlebitic limbs for assessment of valve location. The results indicate that ultrasonic venography is a more accurate method for visualization of valves in this group of patients. Therefore, ultrasonographic imaging is a valuable technique for evaluating limbs with chronic venous insufficiency.

Is hyperbaric oxygen a useful adjunct in the management of problem lower extremity wounds

Hyperbaric oxygen (HBO) is currently being used in the treatment of nonhealing or “problem” wounds of the lower extremities. In an attempt to evaluate the efficacy of HBO in problem wounds, a retrospective study of the HBO experience at Orlando Regional Medical Center was conducted. From 1989 to 1994, fifty-four patients with nonhealing lower extremity wounds resulting from underlying peripheral vascular disease and/or diabetes mellitus were treated with HBO. Wounds were grouped into the following five categories: (1) diabetic ulcers (n=17 [31%]); (2) arterial insufficiency (n=8 [15%]); (3) gangrenous lesions (n=6 [11%]); (4) nonhealing amputation stumps (n=13 [24%]); and (5) nonhealing operative wounds (n=10 [19%]). Each patient received an average of 30 treatments. Outcomes for all 54 patients treated with HBO in this study were dismal. None of the patients experienced complete healing, six (11%) showed some improvement, 43 (80%) showed no improvement, and in five cases (9%) results were inconclusive because these patients underwent concomitant revascularization or amputation. Thirty-eight of the 43 patients who showed no improvement (88%) ultimately required at least one surgical procedure to treat their wounds. Thirty-four patients (63%) developed complications, most commonly barotrauma to the ears, which occurred in 23 patients (43%). The average cost of 30 HBO treatments was

High Ligation of the Greater Saphenous Vein for Treatment of Lower Extremity Varicosities: The Fate of the Vein and Therapeutic Results

14,000 excluding daily inpatient charges. Based on the experience with HBO therapy at Orlando Regional Medical Center and the paucity of good supporting literature, it is difficult to justify such an expensive, ineffective, complication-prone treatment modality for problem extremity wounds.

Origin of deep vein thrombi in an ambulatory population

This study was carried out to determine the subsequent fate of the greater saphenous vein and the efficacy of its high ligation along with surgical excision or sclerotherapy of varicosities. From 1988 to 1990, 22 patients underwent high ligation and sclerotherapy, 22 underwent high ligation and varicose vein excision, and four underwent high ligation alone. There were 36 women and 12 men patients. The average patient age was 48. Sixty limbs were scanned by duplex ultrasound pre- and postoperatively to determine the status of the greater saphenous vein. Average follow-up time was 10 months. Patients and surgeons rated the results of therapy for ablation of varicosities and alleviation of symptoms. Surgical complications were evaluated. At postoperative scan, 47 greater saphenous veins (78%) were found to be completely patent, nine (15%) were thrombosed for a short segment (less than 10 cm) and four (7%) were more significantly thrombosed. Those limbs in which high ligation and sclerotherapy were performed had the highest complete patency rate (96%). Patient and surgeon satisfaction was good to excellent in every case. The only complications were three symptomatic greater saphenous vein thromboses. Although follow-up is relatively brief, complete patency of the ligated greater saphenous vein was found in most cases. High ligation allows preservation of a patent greater saphenous vein, which can be used as an arterial conduit at a later date and gives therapeutic results comparable to stripping without the additional morbidity.

β-Blockade and Operative Mortality in Noncardiac Surgery: Harmful or Helpful?

Eighty symptomatic ambulatory outpatients with acute deep vein thrombosis were evaluated with ascending contrast venography and ultrasonic imaging to determine the origin and distribution of thrombosis and to analyze clinical risk factors. Isolated calf vein thrombosis was present in 42.5 percent of the limbs, combined calf and proximal deep vein thrombosis in 47.5 percent, and isolated proximal thrombosis in 10 percent of the limbs. Discontinuity of thrombus was present in 55 percent, whereas 45 percent exhibited a continuous column of thrombus. The results of this study indicate that in the ambulatory outpatient population, acute deep vein thrombosis begins segmentally in the calf and proximal vessels and frequently coalesces into a continuous column of thrombus over several days. We believe that all cases of acute deep vein thrombosis should be treated and patients with evidence of previous acute deep vein thrombosis should be closely monitored for possible recurrences.

Diagnosis of Recurrent Deep Venous Thrombosis Using B-Mode Ultrasonic Imaging

IMPORTANCE The use of perioperative pharmacologic β-blockade in patients at low risk of myocardial ischemic events undergoing noncardiac surgery (NCS) is controversial because of the risk of stroke and hypotension. Published studies have not found a consistent benefit in this cohort. OBJECTIVE To determine the effect of perioperative β-blockade on patients undergoing NCS, particularly those with no risk factors. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective observational analysis of patients undergoing surgery in Veterans Affairs hospitals from October 1, 2008, through September 31, 2013. METHODS β-Blocker use was determined if a dose was ordered at any time between 8 hours before surgery and 24 hours postoperatively. Data from the Veterans Affairs electronic database included demographics, diagnosis and procedural codes, medications, perioperative laboratory values, and date of death. A 4-point cardiac risk score was calculated by assigning 1 point each for renal failure, coronary artery disease, diabetes mellitus, and surgery in a major body cavity. Previously validated linear regression models for all hospitalized acute care medical or surgical patients were used to calculate predicted mortality and then to calculate odds ratios (ORs). MAIN OUTCOMES AND MEASURES The end point was 30-day surgical mortality. RESULTS There were 326,489 patients in this cohort: 314,114 underwent NCS and 12,375 underwent cardiac surgery. β-Blockade lowered the OR for mortality significantly in patients with 3 to 4 cardiac risk factors undergoing NCS (OR, 0.63; 95% CI, 0.43-0.93). It had no effect on patients with 1 to 2 risk factors. However, β-blockade resulted in a significantly higher chance of death in patients (OR, 1.19; 95% CI, 1.06-1.35) with no risk factors undergoing NCS. CONCLUSIONS AND RELEVANCE In this large series, β-blockade appears to be beneficial perioperatively in patients with high cardiac risk undergoing NCS. However, the use of β-blockers in patients with no cardiac risk factors undergoing NCS increased risk of death in this patient cohort.

A primer on how to select osteopathic applicants to an allopathic general surgery residency

Accurate diagnosis of recurrent deep venous thrombosis (DVT) in patients with postphlebitic syndrome or a history of previous DVT can be extremely difficult. Real-time B-mode ultrasonic imaging (UI) was compared to ascending contrast venography (ACV) in a prospective study of 38 limbs with suspected recurrent DVT to determine if UI could reliably detect recurrent thrombosis. Six limbs had normal deep veins and 32 had evidence of previous DVT by both techniques. Acute thrombus was diagnosed by both UI and ACV in 9 limbs and by UI alone in an additional three limbs. New thrombus was found in 13 popliteal-proximal and 10 calf veins by UI; while ACV detected 12 popliteal-proximal and five new calf vein thromboses. UI is comparable to ACV in detecting recurrent thrombosis and may be particularly useful in assessing the calf veins.

Eagle Syndrome Presenting after Blunt Trauma

As part of Education Week 2009 in Salt Lake City, Utah, the Association of Program Directors in Surgery hosted a panel discussion addressing the integration of osteopathic graduates into allopathic general surgery residency training programs. This article summarizes this panel discussion and the questions asked by members of the audience. With an increasing number of osteopathic medical school graduates, applications to allopathic general surgery residency training programs have been on the rise. Additionally, military scholarships are offered to students at both osteopathic and allopathic schools, increasing the percentage of osteopathic graduates seeking general surgery training in allopathic programs with a military affiliation. The purpose of this work is to provide program directors and faculty members involved with resident selection a primer of information about the expanding role osteopathic physicians, answer potential biases and frequently asked questions about osteopathic applicants and provide practical information on matching osteopathic residents into an allopathic general surgery residency program.