Stephen M. Kavic

Outcome of medical treatment of stricturing and penetrating Crohn's disease: A retrospective study

Background: Outcomes of medical treatment in patients with stricturing and penetrating Crohns disease (CD) are not well characterized. Methods: Adults with stricturing and penetrating CD who underwent medical treatment from 2004 to 2008 were evaluated. We assessed response rates to medical treatment, time to relapse or surgery, and postoperative complications. Results: In all, 53 patients underwent medical therapy. 60% had stricturing disease, 11% had penetrating, and 28% had both. Disease location was ileal in 38%, colonic in 2%, and ileocolonic in 60%. At 30, 60, and 90 days, 54%, 60%, and 64% experienced a response to medical therapy, respectively. At 30 days, 75% of patients with ileal CD responded to therapy compared to 38% of patients with ileocolonic CD (P = 0.026). Overall, 64% of patients required surgery. Patients with ileocolonic disease required surgery at 0.55 years versus 1.07 years in patients with ileal disease (P = 0.023). 24% of patients experienced an anastomotic leak, fistula, or abscess (IASC). 29% of patients with penetrating disease developed IASC compared to 6% of patients with stricturing disease (P = 0.047). 32% of patients on biologic therapy had IASC compared to 0% of those not on biologics (P = 0.059). Conclusions: The outcomes of medical treatment of stricturing or penetrating CD are poor, as 64% ultimately require surgery. Important factors that seem to be associated with either failed therapy include ileocolonic or colonic disease location. We report a high rate of IASC, especially in patients with penetrating disease and those treated with biologic therapy. This should be considered prior to attempted medical therapy. (Inflamm Bowel Dis 2009)

Coupled physical and digital cadaver dissection followed by a visual test protocol provides insights into the nature of anatomical knowledge and its evaluation

This research effort compared and contrasted two conceptually different methods for the exploration of human anatomy in the first‐year dissection laboratory by accomplished students: “physical” dissection using an embalmed cadaver and “digital” dissection using three‐dimensional volume modeling of whole‐body CT and MRI image sets acquired using the same cadaver. The goal was to understand the relative contributions each method makes toward student acquisition of intuitive sense of practical anatomical knowledge gained during “hands‐on” structural exploration tasks. The main instruments for measuring anatomical knowledge under this conceptual model were questions generated using a classification system designed to assess both visual presentation manner and the corresponding response information required. Students were randomly divided into groups based on exploration method (physical or digital dissection) and then anatomical region. The physical dissectors proceeded with their direct methods, whereas the digital dissectors generated and manipulated indirect 3D digital models. After 6 weeks, corresponding student anatomical assignment teams compared their results using photography and animated digital visualizations. Finally, to see whether each method provided unique advantages, a visual test protocol of new visualizations based on the classification schema was administered. Results indicated that all students, regardless of gender, dissection method, and anatomical region dissected performed significantly better on questions presented as rotating models requiring spatial ordering or viewpoint determination responses in contrast to requests for specific lexical feature identifications. Additional results provided evidence of trends showing significant differences in gender and dissection method scores. These trends will be explored with further trials with larger populations. Anat Sci Ed 1:27–40, 2008.

Laparoscopic ventriculoperitoneal shunts: benefits to resident training and patient safety.

This analysis suggests that laparoscopic ventriculoperitoneal shunting may serve as a model to accomplish the goals of improved patient outcomes and quality surgical education.

Classification of hiatal hernias using dynamic three-dimensional reconstruction.

Hiatal hernias and paraesophageal hernias are common clinical entities and have a well-known classification system. Multiple modalities have been used to illustrate these hernias, most relying on artists’ renderings or two-dimensional radiographic studies. However, surgeons would benefit from a comprehensive graphic representation of hiatal hernias based on current imaging technologies. We have applied polygonal mesh surface modeling techniques to render dynamic three-dimensional computed tomography-based models of the four recognized types of hiatal hernias. The resulting images allow nearly real-time navigation in an intuitive and clinically relevant fashion. This model should clarify and eventually advance the existing classification by applying modern and sophisticated image processing to established concepts.

Portal vein thrombosis after splenectomy

We would like to comment on the recent correspondence between Drs Hanazaki and Sugawara regarding portal vein thrombosis (PVT). We have managed a patient who developed PVT after splenectomy for trauma, a cause not cited by Dr Sugawara’s group and not reported in the English literature. Briefly, an otherwise healthy 39-year-old man had a splenic injury after a fall on ice. He underwent splenectomy and had an uneventful recovery. Two weeks later, he presented with malaise, nausea, and mild epigastric pain. CT scan of the abdomen demonstrated mild edema of the small intestine that was interpreted as consistent with PVT. This diagnosis was confirmed by duplex color ultrasonography and magnetic resonance angiography (MRA), which demonstrated complete occlusion of the portal vein. Hematologic workup failed to reveal malignancy or a coagulation disorder, and there was no evidence of thrombocytosis. The patient was treated with systemic anticoagulation and bowel rest with total parenteral nutrition for 2 weeks. MRA was subsequently performed and showed partial flow through the portal vein. Complete resolution of the portal occlusion was documented by duplex scanning 4 months after initial presentation. The incidence of PVT after splenectomy has not been well documented. Clinical signs and symptoms of PVT may be minimal, as in our case, which contributes to the difficulty of diagnosis. But radiographic studies have suggested that the incidence of PVT may be greater than is generally appreciated. One such study demonstrated splenic vein thrombosis in 11% of splenectomized patients imaged with ultrasonography, which, as Rattner and associates stated, may itself lead to PVT. Dr Hanazaki and coworkers highlight the influence of PVT on liver failure and mortality. In our opinion, this relationship mandates a prospective study to determine the incidence, diagnosis, and treatment of PVT for patients undergoing splenectomy. Our experience confirms that PVT may follow any splenectomy, including those for trauma.

Surgical resident accuracy in predicting their ABSITE score.

Background: The American Board of Surgery In-Training Examination (ABSITE) is given to all surgical residents as an assessment tool for residents and their programs in preparation for the American Board of Surgery qualifying and certifying examinations. Our objective was to ascertain how well surgical residents could predict their percentile score on the ABSITE using two predictor measures before and one immediately after the examination was completed. Methods: A survey was given to surgical residents in postgraduate year(s) (PGY) 2 through 5 as well as to research residents in November and December 2011, and immediately after the examination in January 2012, to ascertain their predicted ABSITE scores. Thirty-one general surgery residents were measured consisting of PGY-2 (22%), PGY-3 (19.4%), PGY-4 (19.4%), and PGY-5 (12.9%), and research residents 25.8%. Results: Mean prediction scores were consistently higher than actual examination scores for both junior and senior examination takers, with senior examination predictions exhibiting the highest proportion of variation on the actual examination score. Stratified linear regression analysis showed little predictive significance of all 3 examination predictions and actual score, except for the senior examination predictions in November 2011 (t test = 2.521, P = .027). We found no statistically significant difference in the proportion of residents overestimating or underestimating their predicted score. Secondary analysis using a linear regression model shows that 2011 scores were a statistically significant predictor of 2012 scores (overall F = 13.258, P = .001, R2 = 0.31) for both junior and senior examinations. Conclusion: General surgery residents were not able to accurately predict their ABSITE score; however, the previous years actual scores were found to have the most predictive value of the next years actual scores.

Laparoscopic adrenalectomy for unsuspected unilateral primary adrenal lymphoma.

Laparoscopic surgery for the incidentally enlarged adrenal mass may reveal unexpected findings, such as primary adrenal lymphoma of the large B cell type in this case report. Laparoscopic management proved to be feasible and resulted in minimal surgical morbidity to the patient.

Massive Meckel's enterolith mimicking urachal carcinoma

Meckels enterolith is a rare clinical entity that may be found on imaging and at surgery, as seen in this case of a 68-year-old man presenting for esophagogastrectomy. Images are presented with differential diagnosis and treatment choices.

Endoscopic Placement of Radiopaque Markers for Focused Evaluation of Intestinal Motility

Using traditional techniques in novel ways often can improve management of common surgical problems. Additionally, established products may find new utility when deployed in a slightly different fashion to enhance patient care in a clinically relevant way. This article describes endoscopic placement of radiopaque markers into the proximal small intestine as a means to evaluate motility in a focused fashion. A method to delineate the location of dysmotility in a patient with several potential sites is described. This technique is safe, feasible, reasonably inexpensive, and is easily performed by a skilled endoscopist. Moreover, this technique has the added benefit of providing functional data in a timely fashion.

Defining “Honors”: A Losing Proposition

I read with great interest the recently published article by Drs Lipman and Schenarts. As a program director, I believe it is critically important to find ways of stratifying medical students who are applying for surgery residency. Based on recent experience, I have found that the letter grade or designation of a medical student’s performance no longer carries significant meaning. Almost every student who applies has received an “A,” “Honors,” or “Outstanding” designation. Although I appreciate the authors’ attempt at defining an “honors” student, their approach is fundamentally flawed. To begin with, there is no way to ensure compliance with a rigorous definition. Should a school choose to use the designation “honors,” no one outside that institution can contest that because it is independent of objective criteria. Unfortunately, grade inflation may still persist. Perhaps more importantly, the scoring and application of consensus characteristics are largely subjective. If we are to design a scoring system for the “absence of professionalism issues,” how do we rate those who are “most absent”? Although I agree that enthusiasm is a desirable trait, we have all met the student who is too eager. And in the era of work hour restrictions, how do we properly gauge a student’s work ethic? It is not at all clear how these criteria should be weighted compared with each other, or to the objective number provided by the shelf examination. The authors are to be commended for their attempt to achieve consensus on criteria for an honors designation. However, I believe the characteristics that they enumerate are precisely those traits that come across in well-written letters of recommendation, not in the grade. REFERENCE