Sean Tierney

Physiology and Pathophysiology of Gallbladder Motility

Most significant gallbladder disease is associated with gallbladder stasis. Gallbladder motility is controlled by a complex interplay of hormonal and neural factors. Experimental and clinical studies have demonstrated impaired motility in gallstone disease, and experimental evidence indicates that motility disturbances precede gallstone formation. The ability to measure gallbladder motility clinically has also resulted in better diagnosis and treatment for patients with chronic acalculous cholecystitis.

Carotid endarterectomy--is intensive care unit care necessary?

PURPOSE The purpose of this study was to determine whether postoperative intensive care unit care is necessary for all patients undergoing carotid endarterectomy and whether a subgroup of patients at low-risk not requiring treatment in the intensive care unit could be identified. METHODS Case control analysis of random numbers sample over the last decade of 50% of patients undergoing isolated carotid endarterectomy at a tertiary care hospital. One hundred twenty-nine patients undergoing carotid endarterectomy were identified. Preoperative risk factors, intraoperative course, intensive case unit interventions including vasoactive agents, myocardial ischemia/infarction, arrhythmias, bronchospasm, reintubation, neurologic events, and need for reoperation, were recorded. Timing of interventions, length of stay in intensive care unit, and postoperative course were all recorded. Financial impact was assessed. RESULTS Among 129 patients only 31 patients did not require intensive care unit interventions. A multivariate linear regression analysis demonstrated a model in which a preoperative history of hypertension, myocardial infarction, arrhythmia, and chronic renal failure were 83% predictive of the need for an intensive care unit bed. Specifically, patients could be stratified into a low-risk group before the operation by less than four risk factors. Additionally, all patients requiring interventions or with adverse outcomes were identified by the eight postoperative hour. CONCLUSIONS In preoperative scheduling of intensive care unit beds, patients with less than four risk factors can be stratified to monitoring beds and those with greater than or equal to four can be stratified to intervention beds. After 8 hours, if no interventions are necessary or adverse outcomes occur, then floor recovery is safe. Patients who satisfy this algorithm would save 50% of current intensive care unit charges.

Progesterone alters biliary flow dynamics

OBJECTIVE To test the hypothesis that progesterone alters sphincter of Oddi and gallbladder function and, therefore, bile flow dynamics. SUMMARY BACKGROUND DATA Although the effects of progesterone on the biliary tract have been implicated in the increased incidence of gallstones among women, the specific effects of prolonged elevation of progesterone levels, such as occurs with contraceptive progesterone implants and during pregnancy, on the sphincter of Oddi and biliary flow dynamics are still incompletely understood. METHODS Adult female prairie dogs were randomly assigned to receive subcutaneous implants containing either progesterone or inactive pellet matrix only. Hepatic bile partitioning and gallbladder emptying were determined 14 days later using 99mTc-Mebrofenin cholescintigraphy. RESULTS Significantly less hepatic bile partitioned into the gallbladder in progesterone-treated than in control animals. The gallbladder ejection fraction was significantly reduced from 73+/-6% in controls to 59+/-3% in the progesterone-treated animals. The rate of gallbladder emptying was significantly reduced from 3.6+/-0.3%/minute to 2.9+/-0.1%/minute. CONCLUSIONS Progesterone administered as subcutaneous implants alters partitioning of hepatic bile between gallbladder and small intestine and, therefore, gallbladder filling. Progesterone also significantly impairs gallbladder emptying in response to cholecystokinin. The effects of progesterone on the sphincter of Oddi and the gallbladder may contribute to the greater prevalence of gallstones and biliary motility disorders among women.

Analysing the operative experience of basic surgical trainees in Ireland using a web-based logbook

BackgroundThere is concern about the adequacy of operative exposure in surgical training programmes, in the context of changing work practices. We aimed to quantify the operative exposure of all trainees on the National Basic Surgical Training (BST) programme in Ireland and compare the results with arbitrary training targets.MethodsRetrospective analysis of data obtained from a web-based logbook (http://www.elogbook.org) for all general surgery and orthopaedic training posts between July 2007 and June 2009.Results104 trainees recorded 23,918 operations between two 6-month general surgery posts. The most common general surgery operation performed was simple skin excision with trainees performing an average of 19.7 (± 9.9) over the 2-year training programme. Trainees most frequently assisted with cholecystectomy with an average of 16.0 (± 11.0) per trainee. Comparison of trainee operative experience to arbitrary training targets found that 2-38% of trainees achieved the targets for 9 emergency index operations and 24-90% of trainees achieved the targets for 8 index elective operations. 72 trainees also completed a 6-month post in orthopaedics and recorded 7,551 operations. The most common orthopaedic operation that trainees performed was removal of metal, with an average of 2.90 (± 3.27) per trainee. The most common orthopaedic operation that trainees assisted with was total hip replacement, with an average of 10.46 (± 6.21) per trainee.ConclusionsA centralised web-based logbook provides valuable data to analyse training programme performance. Analysis of logbooks raises concerns about operative experience at junior trainee level. The provision of adequate operative exposure for trainees should be a key performance indicator for training programmes.

Prevalence of lymphoedema and quality of life among patients attending a hospital-based wound management and vascular clinic.

Lymphoedema is a chronic, incurable, debilitating condition, usually affecting a limb and causes discomfort, pain, heaviness, limited motion, unsatisfactory appearance and impacts on quality of life. However, there is a paucity of prevalence data on this condition. This study aimed to determine the prevalence of lymphoedema among persons attending wound management and vascular clinics in an acute tertiary referral hospital. Four hundred and eighteen patients meeting the inclusion criteria were assessed. A prevalence rate of 2.63% (n = 11) was recorded. Thirty‐six percent (n = 4) had history of cellulitis and broken skin, 64% (n = 7) had history of broken skin and 36% (n = 4) had undergone treatment for venous leg ulcers. The most common co‐morbidities were hypertension 55% (n = 6), deep vein thrombosis (DVT) 27% (n = 3), hypercholesterolemia 36% (n = 4) and type 2 diabetes 27% (n = 3). Quality of life scores identified that physical functioning was the domain most affected among this group. This study has identified the need to raise awareness of this condition among clinicians working in the area of wound management.

A targeted e-learning program for surgical trainees to enhance patient safety in preventing surgical infection.

Introduction Surgical site infection accounts for 20% of all health care–associated infections (HCAIs); however, a program incorporating the education of surgeons has yet to be established across the specialty. Methods An audit of surgical practice in infection prevention was carried out in Beaumont Hospital from July to November 2009. An educational Web site was developed targeting deficiencies highlighted in the audit. Interactive clinical cases were constructed using PHP coding, an HTML‐embedded language, and then linked to a MySQL relational database. PowerPoint tutorials were produced as online Flash audiovisual movies. An online repository of streaming videos demonstrating best practice was made available, and weekly podcasts were made available on the iTunes© store for free download. Usage of the e‐learning program was assessed quantitatively over 6 weeks in May and June 2010 using the commercial company Hitslink. Results During the 5‐month audit, deficiencies in practice were highlighted, including the timing of surgical prophylaxis (33% noncompliance) and intravascular catheter care in surgical patients (38% noncompliance regarding necessity). Over the 6‐week assessment of the educational material, the SurgInfection.com Web pages were accessed more than 8000 times; 77.9% of the visitors were from Ireland. The most commonly accessed modality was the repository with interactive clinical cases, accounting for 3463 (43%) of the Web site visits. The average user spent 57 minutes per visit, with 30% of them visiting the Web site multiple times. Discussion Interactive virtual cases mirroring real‐life clinical scenarios are likely to be successful as an e‐learning modality. User‐friendly interfaces and 24‐hour accessibility will increases uptake by surgical trainees.

The impact of a surgical boot camp on early acquisition of technical and nontechnical skills by novice surgical trainees

BACKGROUND Acquisition of skills early in surgical training represents a significant challenge at present because of training time constraints. The aim of this study was to investigate if an intensive surgical boot camp was effective in transferring skills at the beginning of a surgical training program. METHODS New core surgical trainees (n = 58) took part in a 5-day boot camp. There were pretest and posttest assessments of knowledge, technical skills, and confidence levels. The boot camp used simulation and senior surgical faculty to teach a defined range of technical and nontechnical skills. RESULTS The scores for knowledge (53.8% vs 68.4%, P < .01), technical skills (35.9% to 60.6% vs 50.6% to 78.2%, P < .01), and confidence levels improved significantly during boot camp. Skills improvements were still present a year later. CONCLUSION The 5-day surgical boot camp proved to be an effective way to rapidly acquire surgical knowledge and skills while increasing the confidence levels of trainees.

Ethanol inhibits sphincter of Oddi motility

Patients with alcohol-induced liver disease are at increased risk for pigment gallstones, which are known to be particularly associated with biliary stasis. Although the effects of ethanol on the sphincter of Oddi are thought to contribute to alcoholic pancreatitis, the precise effects of ethanol on the biliary component of the sphincter of Oddi are unclear. In the prairie dog the common bile and pancreatic ducts enter the duodenum separately, facilitating pressure measurement in the sphincter choledochus in isolation. We therefore used this model to test the hypothesis that ethanol administration alters sphincter of Oddi motility. Twenty-six male prairie dogs fed a nonlithogenic diet were studied. With the animals under α-chloralose anesthesia, a side-hole pressure-monitored perfusion catheter was positioned in the sphincter of Oddi and femoral arterial and venous catheters were placed. Sphincter of Oddi phasic wave frequency (F), amplitude (A), and motility index (MI = F × A) and arterial blood pressure were monitored at 10-minute intervals before (baseline), during 20-minute intravenous infusions of 15 mg/kg (n = 9), 150 mg/kg (n = 10), and 1.5 g/kg (n = 7) ethanol and for 20 minutes after ethanol infusion. The 15 mg/kg dose of ethanol had no effect, the 150 mg/kg dose tended to reduce sphincter of Oddi motility, and significant reductions in sphincter of Oddi amplitude and motility index were seen at the 1.5 g/kg dose. These data demonstrate that ethanol infusion inhibits both sphincter of Oddi amplitude and motility index and that this effect persists for at least 20 minutes following ethanol infusion. Ethanol may contribute to gallstone formation by altering biliary sphincter motility.

The Brain Drain Myth: Retention of Specialist Surgical Graduates in East, Central and Southern Africa, 1974–2013

BackgroundThis study assesses the retention of specialist surgical graduates from training programmes across eight countries in East, Central and Southern Africa from 1974 to 2013. It addresses the gap in existing data by analysing retention rates of surgical graduates by comparing graduating institution to current location. Data were assessed by country, region, specialty and gender with a view to informing national and regional healthcare and education strategies.MethodsTwenty-five institutions train surgeons in the ten countries covered by the College of Surgeons of East, Central and Southern Africa (COSECSA)—24 Universities and the College itself. These institutions were requested in November 2014 to supply details of graduates from their postgraduate surgical training programmes. Complete graduate lists were returned by the College and 14 universities by March 2016. These surgical graduates were compared against the database of current practising surgeons in the region held by COSECSA. Data were cross-checked against medical council registers, surgical society records, and with members and fellows of COSECSA.ResultsData were incomplete for 126 surgical graduates. Of the remaining 1038 surgical graduates, 85.1% were retained in the country they trained in, while 88.3% were retained within the COSECSA region. Ninety-three per cent (93.4%) were retained within Africa. Of the eight countries, Malawi had the highest retention rate with 100% of surgical graduates remaining in country, while Zimbabwe had the lowest rate with 65.5% remaining.ConclusionHigh surgical graduate retention rates across the region indicate that the expansion of national surgical training initiatives is an effective solution to addressing the surgical workforce shortage in East, Central and Southern Africa and counters long-held arguments regarding brain drain in this region.

Experience of plastic surgery registrars in a European Working Time Directive compliant rota

Abstract Background: Surgical training requires exposure to clinical decision-making and operative experience in a supervised environment. It is recognised that learning ability is compromised when fatigued. The European Working Time Directive requires a decrease in working hours, but compliance reduces trainees’ clinical exposure, which has profound implications for plastic surgery training. The aim of this study was to evaluate plastic surgery registrars’ experience of an EWTD-compliant rota, and to examine its impact on patient care, education, and logbook activity. Methods: An electronic survey was distributed to plastic surgery registrars in a university teaching hospital. Registrars were asked to rate 31 items on a five-point Likert scale, including statements on patient care, clinical and operative duties, training, and quality-of-life. Interquartile deviations explored consensus among responses. Operative caseload was objectively evaluated using eLogbook data to compare activity at equal time points before and after implementation of the EWTD rota. Results: Highest levels of consensus among respondents were found in positive statements addressing alertness and preparation for theatre, as well as time to read and study for exams. Registrars agreed that EWTD compliance improved their quality-of-life. However, it was felt that continuity of patient care was compromised by work hours restriction. Registrars were concerned about their operative experience. eLogbook data confirmed a fall-off in mean caseload of 31.8% compared to activity prior to EWTD rota implementation. Conclusion: While EWTD compliant rotas promote trainee quality-of-life and satisfaction with training, attention needs to be paid to optimising operative opportunities.