Sebastian Demyttenaere

Sim one, do one, teach one: considerations in designing training curricula for surgical simulation.

Although there is considerable interest in the use of simulation for the acquisition of fundamental surgical skills through goal-directed practice in a safe environment, there is little evidence guiding educators on how best to implement simulation within surgical skills curricula. This article reviews the application of the expert performance model in surgery and the role of simulation in surgical skills acquisition. The focus is on implementation of deliberate practice, highlighting the principles of part-task training, proficiency-based training and overtraining. With resident and educator time at a premium, the identification of an optimally effective and efficient training strategy has significant implications for how surgical skills training is incorporated into residency programs, which is critical in todays environment.

Assessing the impact of the trauma team training program in Tanzania.

BACKGROUND In sub-Saharan Africa, injury is responsible for more deaths and disability-adjusted life years than AIDS and malaria combined. The trauma team training (TTT) program is a low-cost course designed to teach a multidisciplinary team approach to trauma evaluation and resuscitation. The purpose of this study was to assess the impact of TTT on trauma knowledge and performance of Tanzanian physicians and nurses; and to demonstrate the validity of a questionnaire assessing trauma knowledge. METHODS This is a prospective study of physicians and nurses from Dar es Salaam undergoing TTT (n = 20). Subjects received a precourse test and, after the course, an alternate postcourse test. The equivalence and construct validity of these 15-item multiple-choice questionnaires was previously demonstrated. After the course, subjects were divided into four teams and underwent a multiple injuries simulation, which was scored with a trauma resuscitation simulation assessment checklist. A satisfaction questionnaire was then administered. Test data are expressed as median score (interquartile ratio) and were analyzed with the Wilcoxons signed rank test. RESULTS After the TTT course, subjects improved their scores from 9 (5-12) to 13 (9-13), p = 0.0004. Team performance scores for the simulation were all >80%. Seventy-five percent of subjects were very satisfied with TTT and 90% would strongly recommend it to others and would agree to teach future courses. CONCLUSIONS After completion of TTT, there was a significant improvement in trauma resuscitation knowledge, based on results from a validated questionnaire. Trauma team performance was excellent when assessed with a novel trauma simulation assessment tool. Participants were very supportive of the course.

Relationship between subjective and objective outcome measures after Heller myotomy and Dor fundoplication for achalasia.

BackgroundThe purpose of this study is to assess how subjective evaluation (heartburn, dysphagia, quality of life, and satisfaction) correlates with objective data after Heller myotomy and Dor fundoplication for achalasia.MethodsA total of 53 consecutive patients with achalasia undergoing laparoscopic Heller myotomy and Dor fundoplication were studied prospectively. Subjective evaluation was done preop and postop using the Gastroesophageal Reflux Disease Health-Related Quality of Life instrument (GERD-HRQL; 0 = best, 45 = worse), 4-point dysphagia and heartburn scales (0 = best, 3 = worst), patient satisfaction scale (0 = very satisfied, 5 = incapacitated), and the SF-12 general health-related quality-of-life score. At 3 months postop, patients were asked to undergo objective evaluation with 24-h pH testing, manometry, and endoscopy. Data are expressed as median (interquartile range) and analyzed by Wilcoxon signed rank test or Mann–Whitney U test.ResultsForty-nine patients were more than 3 months postsurgery. Comparing preop to postop, improvements were found in dysphagia [3 (2–3) to 0 (0–1)], heartburn [1 (0–2) to 0 (0–1)], GERD-HRQL [13.5 (6.3–22.5) to 2 (0–5)], satisfaction [3 (3–4) to 1 (0–1)], and SF-12 mental component summary [46 (37–56) to 58 (50–59)] and physical component summary [46 (36–53) to 55 (48–56)] scores (p < 0.0001 for all). Thirty-eight patients (78%) agreed to undergo objective testing, and complete data were available for 32 (65%). Four of 32 patients (12.5%) had evidence of reflux based on 24-h pH testing. Of nine patients with GERD-HRQL >5, only two had positive pH test (22%). Of 23 patients with GERD-HRQL <5, two had positive pH test (7%). Of four tested patients with moderate to severe heartburn, two had an abnormal pH test. There was no significant relationship between GERD-HRQL score and pH test results. Lower esophageal sphincter pressure (LESP) decreased from 24 (16–35) to 13 mmHg (11–17) (p < 0.001). There was no relationship between dysphagia score and postop absolute LESP or a decrease in LESP after operation.ConclusionsLaparoscopic Heller myotomy and Dor fundoplication is an effective treatment for achalasia. Subjective evaluation can document patient satisfaction and health-related quality of life but does not accurately reflect postop reflux. Twenty-four-hour pH study is required to accurately assess reflux disease.

Does aggressive hydration reverse the effects of pneumoperitoneum on renal perfusion

BackgroundAlthough pneumoperitoneum (PP) decreases renal blood flow, it remains unclear whether this impacts renal function. Our aim was to characterize the effects of PP on renal perfusion and function using two fluid strategies for intravenous fluid administration.MethodsTwelve 30-kg pigs were randomized into two groups: maintenance (3 cc/kg/h of normal saline (NS)) and bolus (15 cc/kg/h + 20 cc/kg NaCl bolus prior to induction of PP). Pigs were studied in a blinded fashion for 30 min prior, 60 min during, and 30 min after release of 15 mmHg CO2 PP. Cardiac output (CO) and stroke volume (SV) were measured using an esophageal Doppler probe, renal cortical perfusion (RCP) was measured with a laser Doppler probe on the right kidney, and renal function was measured using the fractional excretion of sodium (FeNa) and urine output. Statistical analysis was performed with area-under-the-curve (AUC) analysis and analysis of varianceResultsAUC analysis revealed moderate effect size for CO (0.416) and small effect size for SV (0.366) and RCP (0.363), with decreases seen in the control group but not the bolus group. During PP, urine output increased in the bolus group (p = 0.04) but not in the control group; there was no difference in FeNa in either group.ConclusionAggressive fluid hydration during CO2 PP of 15 mmHg preserves CO, SV, and RCP while increasing urine output. No effect on renal function as measured by FeNa was observed in either group.

Elucidating the relationship between cardiac preload and renal perfusion under pneumoperitoneum

IntroductionPneumoperitoneum is associated with a well-described decrease in renal blood flow, but it remains unclear whether a decrease in cardiac preload is responsible. Our aim was to characterize the relationship between cardiac preload and renal perfusion during pneumoperitoneum.MethodsEleven pigs were submitted to three 30 minute study periods: 1) Baseline (n=11): no interventions, 2) Pneumoperitoneum (n=11): 12 mmHg CO2 pneumoperitoneum, 3) Preload Reduction: pneumoperitoneum and nitroglycerin infusion (n=8); or pneumoperitoneum and hemorrhage to a mean arterial pressure (MAP) of 40 mmHg (n=3). Echocardiographic measurements of left ventricular end-diastolic diameter (LVEDD) were used as an index of preload. Renal cortical perfusion (RCP) was measured using laser doppler flowmetry.ResultsLVEDD decreased from 4.2 ± 0.5 to 4.1 ± 0.6 cm (p=0.02) with pneumoperitoneum and then to 4.0 ± 0.5 cm (p=0.03) with the addition of nitroglycerin. There was no statistically significant change in RCP with pneumoperitoneum (33.5 ± 8.4 to 28.5 ± 8.4 ml/min/100g tissue, p=0.2), but it decreased to 18.5 ± 11.3 ml/min/100g tissue (p=0.001) with the addition of nitroglycerin. The correlation between RCP and LVEDD was weak (0.35, p=0.003), whereas correlation between RCP and MAP was superior (R=0.59, p<0.0001).ConclusionsWhile decreasing preload under extreme lab conditions also decreases RCP, simply creating a pneumoperitoneum of 12 mmHg does not. The decrease in renal blood flow associated with pneumoperitoneum is likely not solely a function of preload.

Diabetic Ketoacidosis Following Bariatric Surgery in Patients With Type 2 Diabetes

Diabetic ketoacidosis (DKA) is a life-threatening complication mainly linked to type 1 diabetes. Clinical features of DKA after bariatric surgery are mostly unknown and likely underreported, especially in those with type 2 diabetes. The objective of this study is to emphasize occurrence and clinical presentation of DKA in patients with type 2 diabetes after bariatric surgery. We also aim to describe diagnostic challenges related to new medications such as sodium–glucose cotransporter 2 inhibitors (SGLT-2i) that can cause euglycemic DKA (1,2). We report four cases of DKA in three patients with type 2 diabetes after bariatric surgery at a single institution from January 2010 to December 2015. All cases presented within 30 days following surgery, were classified as moderate to severe based on criteria from the American Diabetes Association (3,4 …

Medium to long-term outcomes of bariatric surgery in older adults with super obesity

BACKGROUND Indications and outcomes of bariatric surgery in older adults suffering from morbid obesity remain controversial. We aimed to evaluate safety and medium to long-term outcomes of bariatric procedures in this patient population. SETTING University Hospital, Canada. METHODS This is a single-center retrospective study of a prospectively collected database. We included patients aged ≥60 years who underwent sleeve gastrectomy, Roux-en-Y gastric bypass, or biliopancreatic diversion with duodenal switch between January 2006 and December 2014 and had at least 2 years of follow-up. RESULTS Of patients, 115 underwent bariatric surgeries (11 patients had 2 procedures). There were 66 were super-obese patients (body mass index>50 kg/m2). Of patients, 74% had sleeve gastrectomy, 16% Roux-en-Y gastric bypass, and 8% underwent biliopancreatic diversion with duodenal switch. Mean age and body mass index were 63.3 ± 2.6 years and 51.7 ± 8.1 kg/m2, respectively. Average follow-up time was 42 ± 19 months. At baseline, 78% had hypertension, 60% had type 2 diabetes, and 30% had obstructive sleep apnea. There was no 30-day mortality. Complication rate was 14% (n = 16): 2 leaks post-Roux-en-Y gastric bypass, 1 leak post-biliopancreatic diversion with duodenal switch, 1 obstruction post-sleeve gastrectomy, 1 bleeding requiring transfusion, 1 liver injury with bile leak, 2 port-site hernias, 1 myocardial infarction, 2 gastrojejunal strictures, 1 wound infection, 1 urinary tract infection, and 3 gastric reflux exacerbations. Mean percent excess weight loss at 2 years was 52.2 ± 23.8. Remission rates of hypertension, type-2 diabetes, and obstructive sleep apnea were 26%, 44%, and 38%, respectively. CONCLUSION Bariatric surgery is safe and effective in improving obesity-related co-morbidities in older patients suffering from morbid obesity. Age alone should not preclude older patients from getting the best bariatric procedure for obesity and related co-morbidities.

An unusual cause of lower gastrointestinal bleeding

A 53-year-old male known for hypertension, chronic renal insufficiency (on hemodialysis), coronary artery disease, and liver transplantation for alcoholic cirrhosis presented to the emergency department because of elevated liver enzymes. He was admitted and treated for obstructive jaundice secondary to a bile duct stricture at the site of the anastomosis. Following endoscopic retrograde cholangiopancreatography and stent insertion, he was kept on his routine immune suppression, which consisted of tacrolimus (Prograf), mycophenolate mofetil, and low-dose steroid therapy. During the course of his hospital stay, he had an episode of tachycardia, mild hypotension, and the passage of large amounts of dark red blood and clots per rectum. There was no abdominal pain or diarrhea. The patient was not known for peptic ulcer disease or nonsteroidal anti-inflammatory drug use but was taking aspirin. His hemoglobin dropped from 90 to 70 g/L. The patient was volume-resuscitated, was transfused, and underwent gastroscopy, which was normal. He subsequently underwent colonoscopy, which demonstrated fresh blood in the cecum. Closer examination revealed a jet of bleeding originating from the orifice of the appendix (Figs. 1 and 2). The cecum was injected with epinephrine in proximity to the appendiceal orifice, and the patient was returned to the floor. However, the patient continued to bleed with significant hemodynamic changes and subsequently underwent superior mesenteric artery angiography. This revealed contrast extravasation from the appendicular artery (Fig. 3), which was subsequently embolized with Gelfoam. Postembolization angiography showed no further blush. The patient rebled and became hypotensive the following day, and at this time it was decided to take the patient to the operating room for an open appendectomy. The appendix was removed in the standard fashion. An intraoperative examination of the specimen revealed a 7-mm superficial mucosal tear of the appendix with adherent clot. Pathology confirmed these findings with no associated tumor, malformation, or foreign body. Immunohistochemistry for cytomegalovirus, adenovirus, and Epstein-Barr virus was negative. The patient recovered from his appendectomy uneventfully and did not experience any further episodes of gastrointestinal bleeding.