Robert A. Kozol

The efficacy of intraoperative methylene blue enemas to assess the integrity of a colonic anastomosis

BackgroundIntraoperative testing of colonic anastomoses is routine in assuring anastamotic integrity. We sought to determine the efficacy of the methylene blue enema (MBE) as an intraoperative test for anastomotic leaks.MethodsThis study is a retrospective review of consecutive colonic operations performed from January 2001 to December 2004 in a community hospital setting by a general surgical group that uses the MBE exclusively. All operations featuring a colonic anastomosis and an intraoperative MBE were studied (n = 229). Intraoperative MBE via a rectal tube was used as the diagnostic test. Intraoperative leak (IOL) rate and clinically significant postoperative leak (POL) rate were the outcome measures.ResultsThe IOL rate was 4.5% for proximal anastomoses, 8% for distal anastomoses, and 7% of total anastomoses. The POL rate was 3% of anastomosis. There were no other testing methods employed. There were no POLs in cases where an IOL led to concomitant intraoperative repair. POL rate for proximal anastomosis was 0.8% and for distal 3%, for stapled 1% and hand sewn 5%.ConclusionMBE IOL rate is comparable to published IOL rates for other methods of intraoperative testing. The MBE can be applied to proximal and distal anastomosis. Patients who were found to have an IOL, and underwent immediate repair, did not develop a clinical POL.

Early colonic anastomotic edema - Evaluation of stapled vs. Hand-sewn anastomoses

Early dysfunction of intestinal anastomoses is sometimes blamed on anastomotic edema. This study compares stapled and hand-sewn anastomoses for the development of early anastomotic edema. After segmental colon resections, one group of dogs was reconstructed with two-layered handsewn anastomoses, and the other group had stapled anastomoses. Controls were untouched small bowel in each operated animal and untouched colon in a separate group of dogs. At 24 hours postoperatively, all animals were given125I albumin and at 28 hours the animals were killed, venous blood was obtained, and the anastomoses were harvested. Tissue levels of125I albumin were measured at 1-mm and 1-cm distances from each anastomosis and compared with controls. This quantitative measure of edema was compared with the histologic appearance of the tissue specimens. The results show significant edema formation in both stapled and handsewn anastomoses compared with control tissues (P<.05 for each animal). Although quantitative and histologic results demonstrate less edema in the stapled group, the difference is not significant by the Wilcoxin rank test. These and similar studies may allow improvement in surgical technique.

Multi-Gene Analysis Reveals a Lack of Genetic Divergence between Calanus agulhensis and C. sinicus (Copepoda; Calanoida)

The discrimination and taxonomic identification of marine species continues to pose a challenge despite the growing number of diagnostic metrics and approaches. This study examined the genetic relationship between two sibling species of the genus Calanus (Crustacea; Copepoda; Calanidae), C. agulhensis and C. sinicus, using a multi-gene analysis. DNA sequences were determined for portions of the mitochondrial cytochrome c oxidase I (mtCOI); nuclear citrate synthase (CS), and large subunit (28S) rRNA genes for specimens collected from the Sea of Japan and North East (NE) Pacific Ocean for C. sinicus and from the Benguela Current and Agulhas Bank, off South Africa, for C. agulhensis. For mtCOI, C. sinicus and C. agulhensis showed similar levels of haplotype diversity (Hd = 0.695 and 0.660, respectively) and nucleotide diversity (π = 0.003 and 0.002, respectively). Pairwise FST distances for mtCOI were significant only between C. agulhensis collected from the Agulhas and two C. sinicus populations: the Sea of Japan (FST = 0.152, p<0.01) and NE Pacific (FST = 0.228, p<0.005). Between the species, FST distances were low for both mtCOI (FST = 0.083, p = 0.003) and CS (FST = 0.050, p = 0.021). Large subunit (28S) rRNA showed no variation between the species. Our results provide evidence of the lack of genetic distinction of C. sinicus and C. agulhensis, raise questions of whether C. agulhensis warrants status as a distinct species, and indicate the clear need for more intensive and extensive ecological and genetic analysis.

Release of neutrophil chemotactic factors from gastric tissue. Initial biochemical characterization.

This study was designed to characterize neutrophil chemotactic factors released by gastric tissue. Full-thickness rabbit stomach (organ culture) was prepared and incubated in Ringers solution at 37°C. Culture supernatants were collected at 1, 2, 3, and 4 hr and assayed for neutrophil chemotactic activity in modified Boyden chambers. High levels of chemotactic activity were seen at 3 hr of incubation. Antral and fundic tissue were equally capable of producing neutrophil chemotactic activity. In addition, high levels of activity were seen from both the serosal and mucosal surfaces. Initial biochemical characterization of these gastricderived factors revealed that: (1) a majority of the activity (80–90%) exhibited molecular weight values of greater than 300 kDa, (2) the chemotactic activity was heat stable but was partially reduced by treatment with a protease, subtilisin (37% inhibition), and (3) 70–80% of the activity in the supernatants was extracted into organic solvent (ethyl acetate). These factors may prove to be important in recruitment of neutrophils to areas of gastric injury.

AVAS Best Clinical Resident Award (Tied): fate of non-designated preliminary general surgery residents seeking a categorical residency position.

BACKGROUND As pyramidal programs in general surgery were eliminated in recent decades, nondesignated preliminary surgery (NDPS) positions were introduced to fill vacant positions. Graduating medical students can pursue NDPS positions with the goal of obtaining categorical positions in either general surgery residencies or other fields altogether. The fate of residents who complete 2 years as NDPS residents remains ill defined. METHODS From 1997 to 2007, data concerning NDPS residents were prospectively collected from 2 general surgery training programs. Trainees were followed by prospectively gathered data, Internet identification, and internal records of hospital privileging. RESULTS One hundred ten graduating medical students initiated postgraduate training as NDPS residents. Seventy-four (67%) were men, and 98 (89%) were international medical graduates. Among all 110 subjects, 95 (86%) were hired as postgraduate year 1 NDPS residents, and 15 (14%) were hired as postgraduate year 2 NDPS residents. Fifteen (14%) left postgraduate medical education. Fifty-two NDPS residents (47%) pursued nonsurgical specialties after their internships. Forty-three (39%) eventually matriculated as categorical general surgical residents. Of these, 20 (47%) became categorical residents in their initial training programs. Nearly all NDPS residents who proceed to categorical positions obtained board certification. CONCLUSIONS More than one third of NDPS residents successfully obtained categorical general surgery positions. Only a small fraction (14%) failed to continue in postgraduate medical education. NDPS positions allow most candidates successful career paths. The persistent rate of attrition among categorical surgical residents allows NDPS residents to join categorical training programs and become eligible for board certification in general surgery.

Post-appendectomy visits to the emergency department within the global period: a target for cost containment.

BACKGROUND Postoperative visits to the emergency department (ED) instead of the surgeons office consume enormous cost. HYPOTHESIS Postoperative ED visits can be avoided. SETTING Fully accredited, single-institution, 617-bed hospital affiliated with the University of Connecticut School of Medicine. PATIENTS Retrospective analysis of 597 consecutive patients with appendectomies over a 4-year period. METHODS Demographic and medical data, at initial presentation, surgery, and ED visit were recorded as categorical variables and statistically analyzed (Pearson chi(2) test, Fisher exact test, and linear-by-linear). Costs were calculated from the hospitals billing department. RESULTS Forty-six patients returned to the ED within the global period with pain (n = 22, 48%), wound-related issues (n = 6, 13%), weakness (n = 4, 9%), fever (13%), and nausea and vomiting (n = 3, 6%). Thirteen patients (28%) required readmission. Predictive factors for ED visit postoperatively were perforated appendicitis (2-fold increase over uncomplicated appendicitis) and comorbidities (cardiovascular or diabetes). The cost of investigations during ED visits was

Mechanical Bowel Obstruction: A Tale of 2 Eras Comment on “Change in Mechanical Bowel Obstruction Demographic and Etiological Patterns During the Past Century”

55,000 plus physician services. CONCLUSIONS ED visits during the postoperative global period are avoidable by identifying patients who may need additional care; improving patient education, optimizing pain control, and improving patient office access.

Association of VA Surgeons annual resident paper award winners: career paths following completion of postgraduate training

1. Markogiannakis H, Messaris E, Dardamanis D, et al. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World J Gastroenterol. 2007;13(3):432-437. 2. Wysocki A, Krzywoń J. Causes of intestinal obstruction. Przegl Lek. 2001;58(6): 507-508. 3. Brasatz E. Zur Schädelttrepanation. Zentralbl Chir. 1989;163:427-429. 4. Obaliński A. Beitrag zur Laparotomie bei interner Darmocclusion. Wiener Med Presse. 1884;25:1525-1527. 5. Obaliński A. Weitere Beiträge zur Laparotomie bei interner Darmocclusion. Wiener Med Presse. 1889;27:108-110. 6. Obaliński A. Ueber secundäre innere Darmocclusion. Wiener Med Presse. 1889; 30:535-536. 7. Obaliński A. Ueber die secundären, des ist, nach Eingriffen am Peritoneum auftretenden darmverschliesungen. Berl Klin Wochenschr. 1889;26:251-255. 8. Obaliński A. Über Laparotomie bei inneren Darmverschluss auf Grund eigener 110 Fälle. Arch Klin Chir. 1894;48:1-53. 9. Obaliński A. Zur Berichtigung der Darmausschaltung mit totalem Verschluss des ausgeschalteten Darmstückes. Centralbl Chir. 1895;22:129-132. 10. Obaliński A. Noch einmal totalen Darmausschaltung mit vollständingen Verschluss. Centralbl Chir. 1896;23:809-814. 11. Obaliński A. Ein weitere Beitrag zur totalen Darmausschaltung. Wiener Med Presse. 1897;38:1092-1094. 12. Rutkowski M. Niedrożność jelit mechaniczna Na podstawie 156 przypadków 188253 [Mechanical bowel obstruction: 156 cases]. In: Zbiór Prac ku Uczczeniu Pamięci Prof dr Alfreda Obalińskiego Czcionkami. Kraków, Poland: Drukarni Uniwersytetu Jagiellońskiego; 1899:188-253. 13. Urbanik R. O wynikach pierworzędnej resekcyi jelita zgorzelinowego w przepuklinach uwięzłych [The results of primary gangrenous bowel resection in obstructed hernias]. In: Zbiór Prac ku Uczczeniu Pamięci Prof. dr Alfreda Obalińskiego Czcionkami. Kraków, Poland: Drukarni Uniwersytetu Jagiellońskiego; 1899: 23-53. 14. Łukasiewicz J. Historia Polski w Liczbach: Ludność Terytorium Główny Urząd Statystyczny Warszawa [History of Poland in Numbers: Population, Territory]. Warsaw, Poland: Central Statistical Office Warsaw; 1994. 15. Demographic Yearbook of Poland 2010. Warsaw, Poland: Central Statistical Office Warsaw; 2010. 16. Ballantyne GH, Brandner MD, Beart RW Jr, Ilstrup DM. Volvulus of the colon: incidence and mortality. Ann Surg. 1985;202(1):83-92. 17. Northeast AD, Dennison AR, Lee EG. Sigmoid volvulus: new thoughts on the epidemiology. Dis Colon Rectum. 1984;27(4):260-261. 18. Öncu M, Piskin B, Calik A, Yandi M, Alhan E. Volvulus of the sigmoid colon. S Afr J Surg. 1991;29(2):48-49. 19. Kössi J, Salminen P, Laato M. The epidemiology and treatment patterns of postoperative adhesion induced intestinal obstruction in Varsinais-Suomi Hospital District. Scand J Surg. 2004;93(1):68-72. 20. Ihedioha U, Alani A, Modak P, Chong P, O’Dwyer P. Hernias are the most common cause of strangulation in patients presenting with small bowel obstruction. Hernia. 2006;10(4):338-340. 21. Schäfer M, Krähenbühl L, Büchler M. Comparison of adhesion formation in open and laparoscopic surgery. Dig Surg. 1998;15(2):148-152. 22. Gutt CN, Oniu T, Schemmer P, Mehrabi A, Büchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc. 2004;18(6):898-906. 23. Delvaux M. Diverticular disease of the colon in Europe: epidemiology, impact on citizen health and prevention. Aliment Pharmacol Ther. 2003;18(suppl 3): 71-74. 24. Neubauer K, Dudkowiak R, Paradowski L. Left-sided diverticulosis of the large bowel as the second most common abnormality in colonoscopy—review of 425 cases of colonic diverticulosis. Adv Clin Exp Med. 2010;19(4):513-518. 25. Painter NS, Burkitt DP. Diverticular disease of the colon: a deficiency disease of Western civilization. BMJ. 1971;2(5759):450-454. 26. Stollman N, Raskin JB. Diverticular disease of the colon. Lancet. 2004;363(9409): 631-639. 27. Strate LL, Liu YL, Aldoori WH, Syngal S, Giovannucci EL. Obesity increases the risks of diverticulitis and diverticular bleeding. Gastroenterology. 2009;136 (1):115.e1-122.e1. doi:10.1053/j.gastro.2008.09.025.

Focused versus screening CT scans for evaluation of nontraumatic abdominal pain in the emergency department

The aims of this study are to track those AVAS podium resident prize winners and to determine patterns of fellowship training type of practice, and primary area of specialization and whether their prize winning paper reflects their current area of specialization today. We also determined whether these residents, once completing their training, ever practiced at a VA hospital, and, whether they have been or currently are members of the AVAS. There have been 43 residents who have won 46 podium awards during this 18 year period. Three/46 (6%) awards were won by a resident twice during different years. Among the 42 locatable residents, 3/42 (7%) are still in surgery training. Among those 39 who are in practice, 30/39 (76%) undertook a clinical fellowship and 22/39 (56%) are in an academic setting. Only 3/39 (8%) has ever worked at a VA hospital; all 3 are currently members of the AVAS. Among those with a specific area of clinical or research specialization (n = 32), in 25/32 (78%), their paper reflects their current area of specialization. Among our cohort of annual AVAS resident prize winners most have taken fellowship training. Greater than 50% pursue academic practice. Among those with an area of specialization, their prize winning paper reflects on their current area of specialization today. Few have ever worked in a VA hospital and thus few have ever been members of the AVAS.

Frank Hastings Hamilton: Medical educator and surgeon to president Garfield

Objective To evaluate the utility of computed tomography (CT) scans in patients with abdominal pain in the emergency department. We compared focused scans (having a single diagnosis in mind) and screening scans (having no diagnosis or more than one diagnosis in mind) with the hypothesis that focused scans will reveal pathology more often than screening scans. Treatment plans and patient outcomes were also compared between the two populations. Methods This is a prospective study in which 100 patients who presented to an academic medical center with abdominal pain and underwent an abdominal CT were enrolled in the study. A chart review was later completed to gather ultimate outcome data for each of the enrolled subjects. Results Of the 61 patients having a focused CT, pathology was identified on 63.9% of the scans, which did not differ significantly from the 65.4% of scans that revealed pathology in the screening group. In the focused group, anticipated admissions were reduced, but the reduction was not significant. The screening group did show a significant difference, with eight fewer patients being admitted than initially planned. The total number of patients deemed to require admission was significantly reduced by 15% following all CT scans. Conclusion While there was no difference between the focused and screening groups in the rate of identifying pathology, there was a significant decline in number of patients requiring admission to the hospital in the “screening” CT group (when comparing emergency physicians’ pre- and post-CT treatment plans).