Robert D. Acton

When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum

BACKGROUND/PURPOSE Pectus excavatum is a common chest wall deformity, and several procedures have been developed for its correction. We allow patients to choose among Leonard, Nuss, and Ravitch procedures. This study aimed to determine which procedure most patients select and the resultant outcomes. METHODS Charts were reviewed of all pectus excavatum repairs performed for 4 years by a practice covering a university-based childrens hospital. Procedure choice, operative time, length of stay, analgesia, fees, and complications were recorded. RESULTS The Ravitch procedure was chosen by 60.9% of our patients, Leonard procedure by 23.9%, and Nuss procedure by 15.2%. Operative times were not significantly different among the groups. The mean length of stay was 2.2 days (Ravitch), 1.5 days (Leonard), and 3.9 days (Nuss) (P < .005). Epidural analgesia/patient-controlled analgesia pump requirements were 50% (Ravitch), 5% (Leonard), and 100% (Nuss). The mean charges were

American College of Surgeons/Association for Surgical Education medical student simulation-based surgical skills curriculum needs assessment.

27,414 (Ravitch),

Retrospective review of reoperative pectus excavatum repairs

18,094 (Leonard), and

Improving surgery intern confidence through the implementation of expanded orientation sessions

43,749 (Nuss) (P < .05). The overall complication rate was 16.3%. The complications among each group were as follows: Ravitch, 14.3%; Leonard, 9.1%; and Nuss, 35.7%. CONCLUSIONS We allow patients to choose among Leonard, Ravitch, and Nuss procedures for repair of pectus excavatum. Most select the Ravitch procedure. Length of stay, fees, analgesic needs, and complication rate were highest among patients in the Nuss group; all of these variables were lowest in the Leonard group.

Management of giant omphaloceles: A systematic review of methods of staged surgical vs. nonoperative delayed closure

BACKGROUND Simulation can enhance learning effectiveness, efficiency, and patient safety and is engaging for learners. METHODS A survey was conducted of surgical clerkship directors nationally and medical students at 5 medical schools to rank and stratify simulation-based educational topics. Students applying to surgery were compared with others using Wilcoxons rank-sum tests. RESULTS Seventy-three of 163 clerkship directors (45%) and 231 of 872 students (26.5%) completed the survey. Of students, 28.6% were applying for surgical residency training. Clerkship directors and students generally agreed on the importance and timing of specific educational topics. Clerkship directors tended to rank basic skills, such as examination skills, higher than medical students. Students ranked procedural skills, such as lumbar puncture, more highly than clerkship directors. CONCLUSIONS Surgery clerkship directors and 4th-year medical students agree substantially about the content of a simulation-based curriculum, although 4th-year medical students recommended that some topics be taught earlier than the clerkship directors recommended. Students planning to apply to surgical residencies did not differ significantly in their scoring from students pursuing nonsurgical specialties.

Design of a potent novel endotoxin antagonist

BACKGROUND/PURPOSE Despite success of several techniques described for pectus excavatum repair, a minority of patients require multiple reoperations for recurrence or other complications. We aimed to review our experience in reoperative pectus excavatum repairs and to identify features correlating with need for additional reoperations. METHODS Charts were reviewed of all patients undergoing reoperative pectus excavatum repair for 3 years at a university-based childrens hospital. Number and type of previous repairs, time between operations, lengths of stay, analgesia, and complications were recorded. RESULTS From February 2004 to December 2007, 170 pectus excavatum repairs were performed. Among these, 27 were reoperative. Overall, 18.2% of reoperative patients required subsequent additional reoperations. 21.1% of patients undergoing repeat open repairs and 33.3% of patients undergoing repeat minimally invasive repairs required further operative interventions. There was no need for additional repairs among patients who had open repairs after minimally invasive repairs, nor for any patients who had minimally invasive repairs after open repairs. CONCLUSIONS We conclude that patients with failed open repairs will have better success with minimally invasive reoperations, whereas patients with failed minimally invasive repairs will have better success with open reoperations. When faced with reoperative pectus excavatum, we recommend consideration of an alternative operative approach from the initial procedure.

The Evolving Role of Simulation in Teaching Surgery in Undergraduate Medical Education

BACKGROUND New surgical interns may be unprepared for job-related tasks and harbor anxiety that could interfere with job performance. To address these problems, we extended our intern orientation with the principal aim of demonstrating the need for expanded instruction on execution of daily tasks. Additionally, we sought to show that an enriched orientation curriculum durably augments intern confidence. METHODS Twenty-one surgical interns participated in an extended orientation program, consisting of interactive didactics, case scenario presentations, and small group discussions. Evaluations collected at completion of orientation and 1-month follow-up assessed self-reported confidence levels on job-related tasks before, immediately afterward, and 1-month after orientation. Statistical analyses were performed using Student t tests (P < .05 significant). RESULTS Self-reports of confidence on job-related tasks before the orientation sessions were low; however, program participation resulted in immediate confidence increases in all areas. Evaluations at 1-month follow-up showed persistence of these gains. CONCLUSION Interns reported considerable anxiety in all job-related tasks before orientation. After the sessions, confidence levels were significantly and durably improved in all areas. Our findings suggest the need for specific instruction on job-related tasks of surgical internship and demonstrate the effectiveness of an expanded orientation in improving intern confidence in execution of these tasks.

Clostridium difficile infection in the pediatric surgery population

PURPOSE Despite the numerous methods of closure for giant omphaloceles, uncertainty persists regarding the most effective option. Our purpose was to review the literature to clarify the current methods being used and to determine superiority of either staged surgical procedures or nonoperative delayed closure in order to recommend a standard of care for the management of the giant omphalocele. METHODS Our initial database search resulted in 378 articles. After de-duplification and review, we requested 32 articles relevant to our topic that partially met our inclusion criteria. We found that 14 articles met our criteria; these 14 studies were included in our analysis. 10 studies met the inclusion criteria for nonoperative delayed closure, and 4 studies met the inclusion criteria for staged surgical management. RESULTS Numerous methods for managing giant omphaloceles have been described. Many studies use topical therapy secondarily to failed surgical management. Primary nonoperative delayed management had a cumulative mortality of 21.8% vs. 23.4% in the staged surgical group. Time to initiation of full enteric feedings was lower in the nonoperative delayed group at 14.6days vs 23.5days. CONCLUSION Despite advances in medical and surgical therapies, giant omphaloceles are still associated with a high mortality rate and numerous morbidities. In our analysis, we found that nonoperative delayed management with silver therapy was associated with lower mortality and shorter duration to full enteric feeding. We recommend that nonoperative delayed management be utilized as the primary therapy for the newborn with a giant omphalocele.

Mucosal nerve deficiency in chronic childhood constipation: a postmigration defect?

BACKGROUND Bactericidal permeability increasing protein (BPI) binds to and neutralizes lipopolysaccharide (LPS, endotoxin). Small synthetic peptides based on the amino acid sequence of the LPS binding domain of BPI neutralize LPS, albeit inefficiently. Although the LPS binding domain of native BPI possesses a beta-turn secondary structure, this structure is not present in small derivative peptides. The purpose of this study was to determine whether the addition of a beta-turn to a BPI-derived peptide is associated with more potent endotoxin antagonism. METHODS We generated a hybrid peptide (BU3) on the basis of (1) a portion of the LPS binding domain from BPI and (2) amino acids known to initiate a beta-turn. BU3 folds with a beta-turn, and we tested its effects on LPS neutralization and LPS-induced tumor necrosis factor-alpha secretion, comparing it with BPI-derived peptide BG22 that lacks a beta-turn and to an irrelevant peptide (BG16). RESULTS Compared with BG22, BU3 demonstrated enhanced LPS neutralization and inhibition of LPS-induced tumor necrosis factor-alpha secretion in vitro and a similar diminution of endotoxemia and tumor necrosis factor-alpha secretion in a murine model of endotoxemia. CONCLUSIONS These data demonstrate the potential for enhancing the biologic activity of a BPI-derived peptide endotoxin antagonist via manipulation of its conformational structure.

Minimally Invasive Adenocarcinoma of the Lung as Second Malignant Neoplasm Following Pediatric Rhabdomyosarcoma

Simulation-based training (SBT) over the last 10 years has become a mainstay for surgical education at the graduate medical education (GME) level. More recently, however, the technique has rapidly become the standard for early efficient teaching of surgical skills and decision making at the undergraduate medical education (UME) level. The described benefits of SBT include its ability to compartmentalize education, to combine immediate assessment and feedback, and to accelerate knowledge and skill acquisition for the young learner. Consequently, SBT is now being adopted in multiple national medical student surgical educational initiatives.