JAMA Surgery Current Issue

About This Journal

Wed, 01 May 2013 00:00:00 GMT

Characteristics of Highly Ranked Applicants to General Surgery Residency Programs: Are We Assessing the Right Criteria? Comment on “Characteristics of Highly Ranked Applicants to General Surgery Residency Programs” Characteristics of Highly Ranked Applicants

Hebert JC. — Wed, 01 May 2013 00:00:00 GMT

The annual ritual of screening Electronic Residency Application Service applications, reading personal statements, and interviewing candidates to create a ranking for the residency match is time consuming and may be frustrating if a program does not match with its top candidates. Perhaps most concerning to the process is that some of our most highly ranked candidates actually do not perform well as residents, and a few fail completely.

Characteristics of Highly Ranked Applicants to General Surgery Residency Programs Characteristics of Applicants to GSR

Stain SC, Hiatt JR, Ata A, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

With duty hour debates, specialization, and sex distribution changes in the applicant pool, the relative competitiveness for general surgery residency (GSR) is undefined.

Objective

To determine the modern attributes of top-ranked applicants to GSR.

Design

Validation cohort, survey.

Setting

National sample of university and community-based GSR programs.

Participants

Data were abstracted from Electronic Residency Application Service files of the top 20–ranked applicants to 22 GSR programs. We ranked program competitiveness and blinded review of personal statements.

Main Outcomes and Measures

Characteristics associated with applicant ranking by the GSR program (top 5 vs 6-20) and ranking by highly competitive programs were identified using t and χ² tests and modified Poisson regression.

Results

There were 333 unique applicants among the 440 Electronic Residency Application Service files. Most applicants had research experience (93.0%) and publications (76.8%), and 28.4% had Alpha Omega Alpha membership. Nearly half were women (45.2%), with wide variation by program (20.0%-75.0%) and a trend toward fewer women at programs in the South and West (38.0% and 37.5%, respectively). Men had higher United States Medical Licensing Examination Step 1 scores (238.0 vs 230.1; P < .001) but similar Step 2 scores (245.3 vs 244.5; P = .54). Using bivariate analysis, highly competitive programs were more likely to rank applicants with publications, research experience, Alpha Omega Alpha membership, higher Step 1 scores, and excellent personal statements and those who were male or Asian. However, the only significant predictors were Step 1 scores (relative risk [RR], 1.36 for every 10-U increase), publications (RR, 2.20), personal statements (RR, 1.62), and Asian race (RR, 1.70 vs white). Alpha Omega Alpha membership (RR, 1.62) and Step 1 scores (RR, 1.01) were the only variables predictive of ranking in the top 5.

Conclusions and Relevance

This national sample shows GSR is a highly competitive, sex-neutral discipline in which academic performance is the most important factor for ranking, especially in the most competitive programs. This study will inform applicants and program directors about applicants to the GSR program.

Early Diagnosis of Metastatic Disease in Melanoma: Does It Make a Difference? Comment on “Long-term Follow-up and Survival of Patients Following a Recurrence of Melanoma After a Negative Sentinel Lymph Node Biopsy Result” Early Diagnosis of Metastatic Disease in Melanoma

Wong JH. — Wed, 01 May 2013 00:00:00 GMT

An area of continuing controversy with regard to melanoma is the therapeutic value of a sentinel lymph node biopsy (SLNB). An interim analysis of the Multicenter Selective Lymphadenectomy Trial I failed to demonstrate an improvement in melanoma-specific survival for patients undergoing an SLNB compared with patients who were only observed. For this reason, some have questioned the role of an SLNB in an era when adjuvant therapy remains controversial.

Effects of Duty Hour Restrictions on Core Competencies, Education, Quality of Life, and Burnout Among General Surgery Interns Effects of Duty Hour Restrictions

Antiel RM, Reed DA, Van Arendonk KJ, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To measure the implications of the new Accreditation Council for Graduate Medical Education duty hour regulations for education, well-being, and burnout.

Design

Longitudinal study.

Setting

Eleven university-based general surgery residency programs from July 2011 to May 2012.

Participants

Two hundred thirteen surgical interns.

Main Outcome Measures

Perceptions of the impact of the new duty hours on various aspects of surgical training, including the 6 Accreditation Council for Graduate Medical Education core competencies, were measured on 3-point scales. Quality of life, burnout, balance between personal and professional life, and career satisfaction were measured using validated instruments.

Results

Half of all interns felt that the duty hour changes have decreased the coordination of patient care (53%), their ability to achieve continuity with hospitalized patients (70%), and their time spent in the operating room (57%). Less than half (44%) of interns believed that the new standards have decreased resident fatigue. In longitudinal analysis, residents' beliefs had significantly changed in 2 categories: less likely to believe that practice-based learning and improvement had improved and more likely to report no change to resident fatigue (P < .01, χ² tests). The majority (82%) of residents reported a neutral or good overall quality of life. Compared with the normal US population, 50 interns (32%) were 0.5 SD less than the mean on the 8-item Short Form Health Survey mental quality of life score. Approximately one-third of interns demonstrated weekly symptoms of emotional exhaustion (28%) or depersonalization (28%) or reported that their personal-professional balance was either “very poor” or “not great” (32%). Although many interns (67%) reported that they daily or weekly reflect on their satisfaction from being a surgeon, 1 in 7 considered giving up their career as a surgeon on at least a weekly basis.

Conclusions

The first cohort of surgical interns to train under the new regulations report decreased continuity with patients, coordination of patient care, and time spent in the operating room. Furthermore, suboptimal quality of life, burnout, and thoughts of giving up surgery were common, even under the new paradigm of reduced work hours.

Fate of the Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis Fate of the Retained Rectum

Munie S, Hyman N, Osler T. — Wed, 01 May 2013 00:00:00 GMT

Importance

Total proctocolectomy with ileal pouch–anal anastomosis is considered the procedure of choice for patients requiring elective surgery for ulcerative colitis, but some patients undergoing subtotal colectomy with end ileostomy are satisfied with an ileostomy and do not choose to undergo later pelvic pouch surgery. The need and timing for completion proctectomy in this setting are uncertain.

Objective

To assess the long-term fate of the retained rectum compared with the morbidity associated with completion proctectomy in patients who underwent subtotal colectomy for ulcerative colitis.

Design and Setting

Retrospective review of a prospective database in an academic medical center.

Participants

Patients who underwent subtotal colectomy with ileostomy for ulcerative colitis from July 1, 1990, to December 31, 2010.

Main Outcomes and Measures

Proctectomy, surgical complications, and symptoms from the retained rectum.

Results

One hundred eight patients underwent subtotal colectomy for ulcerative colitis during the study period: 73 for acute disease, 18 for advanced age and/or comorbidities, and 17 to avoid the risk of sexual dysfunction or infertility. Of these patients, 71 (65.7%) underwent subsequent ileal pouch–anal anastomosis, 2 died of other causes, and 3 were lost to follow-up. Of the remaining 32 patients, 20 chose rectal stump surveillance and 12 underwent elective proctectomy. Median follow-up was 13.8 years. No difference was noted in age, sex, surgical complications, pad use, or urinary dysfunction between the 2 groups. Only 8 of 20 patients in the surveillance group were compliant with follow-up endoscopy, and 13 were able to maintain their rectum; 2 required proctectomy at 11 and 16 years, respectively, for rectal cancer; neither has developed recurrent disease. One patient in each group reported erectile dysfunction.

Conclusions and Relevance

Management of the retained rectum after subtotal colectomy remains an important issue even in the era of ileal pouch–anal anastomosis. Considering the risk of rectal cancer, the low success rate of long-term rectal preservation, and the safety of surgery, a more aggressive approach to early completion proctectomy seems justified in this situation.

FDA Delays Decision to Remove Powdered Gloves FDA Delays Decision to Remove Powdered Gloves

Edlich RF, Garrison JA, Smith WB. — Wed, 01 May 2013 00:00:00 GMT

The Food and Drug Administration (FDA) requires scientists to prepare a Citizen Petition to request changes in its mandatory regulations regarding the safety of drugs and devices.

Image of the Month—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Image of the Month—Diagnosis

Wed, 01 May 2013 00:00:00 GMT

Image of the Month—Quiz Case

Kuy S, Vickery M, Dua A, et al. — Wed, 01 May 2013 00:00:00 GMT

A 37-year-old woman with a history of cyclic lower abdominal pain and nausea presented to the emergency department with acute-onset right lower quadrant (RLQ) pain and nausea for 1 day, but no fever. Vital signs were normal. Physical examination revealed RLQ tenderness. Laboratory examination included a urinalysis, the result of which was negative, and a white blood cell count, which revealed a mild leukocytosis of 11.6 K/μL. Pelvic ultrasonography was obtained, which showed a right ovarian cyst but without evidence of torsion. Computed tomography (CT) of the abdomen/pelvis was performed, which showed an enlarged, dilated appendix of 11 mm in diameter (Figure 1), which on comparison with a prior CT examination from 5 years prior showed a similarly enlarged, dilated appendix.

Image of the Month—Quiz Case

Adachi K, Takuma K, Enatsu K, et al. — Wed, 01 May 2013 00:00:00 GMT

A 33-year-old man visited the hospital with marked abdominal distention and vomiting. His medical history included epilepsy and mild mental retardation. He had no previous surgery or abdominal trauma history. Physical examination revealed a nontender, huge tumor palpable in the gross abdomen. Laboratory workup disclosed no abnormalities. An abdominal computed tomographic scan also showed a giant solid lesion occupying the entire abdominal cavity (Figure 1A). Angiography showed that the tumor was supplied by the bilateral internal iliac arteries, lumbar arteries, and branches of the superior and inferior mesenteric arteries (Figure 1B). Excisional biopsy under local anesthesia was carried out to confirm proliferation of spindle and epithelioid cells. Although the definitive diagnosis was uncertain at that time, exploratory laparotomy was carried out. He underwent en bloc tumor extirpation with resection of the sigmoid colon and distal ileum. The resected tumor was approximately 35 × 25 × 10 cm and weighed 4400 g. Pathological investigation revealed dense proliferation of spindle-shaped cells arranged in fascicles (Figure 2A). The immune profile of the tumor subsequently yielded positive expression of S-100 protein (Figure 2B), whereas there was negative staining of desmin.

Immunocompromised Status in Patients With Necrotizing Soft-Tissue Infection Immunocompromised Status and Soft-Tissue Infection

Keung EZ, Liu X, Nuzhad A, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

There is a scarcity of research on immunocompromised patients with necrotizing soft-tissue infection (NSTI).

Objective

To evaluate the effect of immunocompromised status in patients with NSTI.

Design and Setting

Single-institution retrospective cohort study at a tertiary academic teaching hospital affiliated with a major cancer center.

Participants

Patients with NSTI.

Exposure

Treatment at Brigham and Women's Hospital and Dana-Farber Cancer Institute between November 25, 1995, and April 25, 2011.

Main Outcome and Measure

Necrotizing soft-tissue infection–associated in-hospital mortality.

Results

Two hundred one patients were diagnosed as having NSTI. Forty-six were immunocompromised (as defined by corticosteroid use, active malignancy, receipt of chemotherapy or radiation therapy, diagnosis of human immunodeficiency virus or AIDS, or prior solid organ or bone marrow transplantation with receipt of chronic immunosuppression). At presentation, immunocompromised patients had lower systolic blood pressure (105 vs 112 mm Hg, P = .02), glucose level (124 vs 134 mg/dL, P = .03), and white blood cell count (6600/μL vs 17 200/μL, P < .001) compared with immunocompetent patients. Immunocompromised patients were less likely to have been transferred from another institution (26.1% vs 52.9%, P = .001), admitted to a surgical service (45.7% vs 83.2%, P < .001), or undergone surgical debridement on admission (4.3% vs 61.3%, P = .001). Time to diagnosis and time to first surgical procedure were delayed in immunocompromised patients (P < .001 and P = .001, respectively). Immunocompromised patients had higher NSTI-associated in-hospital mortality (39.1% vs 19.4%, P = .01).

Conclusions and Relevance

Immunocompromised status in patients with NSTI in this study is associated with delays in diagnosis and surgical treatment and with higher NSTI-associated in-hospital mortality. At presentation, immunocompromised patients may fail to exhibit typical clinical and laboratory signs of NSTI. Physicians caring for similar patient populations should maintain a heightened level of suspicion for NSTI and consider early surgical evaluation and treatment.

Investigating the Causes of Trauma: Critical Initial Steps to Designing Sustainable Interventions in Sierra Leone Comment on “Traumatic Injuries in Developing Countries” Investigating the Causes of Trauma

Price R. — Wed, 01 May 2013 00:00:00 GMT

The numbers of publications addressing road traffic injuries in Sub-Saharan Africa are embarrassingly a fraction of those examining human immunodeficiency virus/AIDS. Yet, trauma kills more people worldwide than human immunodeficiency virus, malaria, and tuberculosis combined. Stewart et al are to be commended for adding to a growing body of evidence of the significant role injury plays in public health for a low-income country. Developing countries lacking public health interventions and access to timely and appropriate care continue to experience increasing morbidity and mortality from preventable injuries. Identifying the significant role injury plays in the overall burden of disease, and understanding the basic epidemiology in developing countries, provides an essential framework for designing life-saving interventions. In 1951, Learmonth said that

Is the Elimination of Postoperative Antimicrobial Prophylaxis in Thoracic Surgery Ready for Prime Time? Comment on “Postoperative Antibacterial Prophylaxis for the Prevention of Infectious Complications Associated With Tube Thoracostomy in Patients Undergoing Elective General Thoracic Surgery” Postoperative Antimicrobial Prophylaxis in Surgery

Sanchez JA. — Wed, 01 May 2013 00:00:00 GMT

Many retrospective series conclude with the admonition that the findings should be corroborated by a well-designed, randomized clinical trial. With regard to the use of antibiotics following thoracic surgery, that study is now available. Oxman and colleagues provide us with a well-conducted, randomized study suggesting that routinely extending antimicrobial prophylaxis into the postoperative period is of no value in preventing infectious complications following thoracic surgery involving tube thoracostomy.

Long-term Follow-up and Survival of Patients Following a Recurrence of Melanoma After a Negative Sentinel Lymph Node Biopsy Result Recurrence of Melanoma After Negative SLNB Result

Jones EL, Jones TS, Pearlman NW, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To analyze the predictors and patterns of recurrence of melanoma in patients with a negative sentinel lymph node biopsy result.

Design

Retrospective chart review of a prospectively created database of patients with cutaneous melanoma.

Setting

Tertiary university hospital.

Patients

A total of 515 patients with melanoma underwent a sentinel lymph node biopsy without evidence of metastatic disease between 1996 and 2008.

Main Outcome Measures

Time to recurrence and overall survival.

Results

Of 515 patients, 83 (16%) had a recurrence of melanoma at a median of 23 months during a median follow-up of 61 months (range, 1-154 months). Of these 83 patients, 21 had melanoma that metastasized in the studied nodal basin for an in-basin false-negative rate of 4.0%. Patients with recurrence had deeper primary lesions (mean thickness, 2.7 vs 1.8 mm; P < .01) that were more likely to be ulcerated (32.5% vs 13.5%; P < .001) than those without recurrence. The primary melanoma of patients with recurrence was more likely to be located in the head and neck region compared with all other locations combined (31.8% vs 11.7%; P < .001). Median survival following a recurrence was 21 months (range, 1-106 months). Favorable characteristics associated with lower risk of recurrence included younger age at diagnosis (mean, 49 vs 57 years) and female sex (9% vs 21% for males; P < .001).

Conclusion

Overall, recurrence of melanoma (16%) after a negative sentinel lymph node biopsy result was similar to that in previously reported studies with an in-basin false-negative rate of 4.0%. Lesions of the head and neck, the presence of ulceration, increasing Breslow thickness, older age, and male sex are associated with increased risk of recurrence, despite a negative sentinel lymph node biopsy result.

Postoperative Antibacterial Prophylaxis for the Prevention of Infectious Complications Associated With Tube Thoracostomy in Patients Undergoing Elective General Thoracic Surgery A Double-blind, Placebo-Controlled, Randomized Trial Postoperative Antibacterial Prophylaxis

Oxman DA, Issa NC, Marty FM, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To determine whether extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery with tube thoracostomy reduces the risk of infectious complications compared with preoperative prophylaxis only.

Design

Prospective, randomized, double-blind, placebo-controlled trial.

Setting

Brigham and Women's Hospital, an 800-bed tertiary care teaching hospital in Boston, Massachusetts.

Participants

A total of 251 adult patients undergoing elective thoracic surgery requiring tube thoracostomy between April 2008 and April 2011.

Interventions

Patients received preoperative antibacterial prophylaxis with cefazolin sodium (or other drug if the patient was allergic to cefazolin). Postoperatively, patients were randomly assigned (at a 1:1 ratio) using a computer-generated randomization sequence to receive extended antibacterial prophylaxis (n = 125) or placebo (n = 126) for 48 hours or until all thoracostomy tubes were removed, whichever came first.

Main Outcome Measures

The combined occurrence of surgical site infection, empyema, pneumonia, and Clostridium difficile colitis by postoperative day 28.

Results

A total of 245 patients were included in the modified intention-to-treat analysis (121 in the intervention group and 124 in the placebo group). Thirteen patients (10.7%) in the intervention group and 8 patients (6.5%) in the placebo group had a primary end point (risk difference, −4.3% [95% CI, −11.3% to 2.7%]; P = .26). Six patients (5.0%) in the intervention group and 5 patients (4.0%) in the placebo group developed surgical site infections (risk difference, −0.93% [95% CI, −6.1% to 4.3%]; P = .77). Seven patients (5.8%) in the intervention group and 3 patients (2.4%) in the placebo group developed pneumonia (risk difference, −3.4% [95% CI, −8.3% to 1.6%]; P = .21). One patient in the intervention group developed empyema. No patients experienced C difficile colitis.

Conclusions

Extended postoperative antibacterial prophylaxis for patients undergoing elective thoracic surgery requiring tube thoracostomy did not reduce the number of infectious complications compared with preoperative prophylaxis only.

Trial Registration

clinicaltrials.gov Identifier: NCT00818766

Surgical Residents' Perceptions of 2011 Accreditation Council for Graduate Medical Education Duty Hour Regulations Perceptions of 2011 ACGME Duty Hour Regulations

Drolet BC, Sangisetty S, Tracy TF, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

In 2010, the Accreditation Council for Graduate Medical Education (ACGME) proposed increased regulation of work hours and supervision for residents. New Common Program requirements that took effect in July 2011 dramatically changed the customary 24-hour in-house call schedule. Surgical residents are more likely to be affected by these duty hour restrictions.

Objective

To examine surgical residents' views of the 2011 ACGME Common Program requirements after implementation in July 2011.

Design

A 20-question electronic survey was administered 6 months after implementation of 2011 ACGME regulations to 123 participating institutions.

Setting

ACGME-accredited teaching hospitals in the United States and US territories.

Participants

The total sample was 1013 voluntarily participating residents in general surgery and surgical specialties at ACGME-accredited institutions.

Main Outcomes and Measures

Residents' perceptions of changes in education, patient care, and quality of life after institution of 2011 ACGME duty hour regulations and their compliance with these rules.

Results

A subset of 1013 residents training in general surgery or a surgical subspecialty was identified from a demographically representative sample of 6202 survey respondents. Most surgical residents indicated that education (55.1%), preparation for senior roles (68.4%), and work schedules (50.7%) are worse after implementation of the 2011 regulations. They reported no change in supervision (80.8%), safety of patient care (53.4%), or amount of rest (57.8%). Although quality of life is perceived as better for interns (61.9%), most residents believe that it is worse for senior residents (54.4%). A majority report increased handoffs (78.2%) and a shift of junior-level responsibilities to senior residents (68.7%). Finally, many residents report noncompliance (67.6%) and duty hour falsification (62.1%).

Conclusions and Relevance

A majority of surgical residents disapprove of 2011 ACGME Common Program requirements (65.9%). The proposed benefits of the increased duty hour restrictions—improved education, patient care, and quality of life—have ostensibly not borne out in surgical training. It may be difficult for residents, particularly in surgical fields, to learn and care for patients under the 2011 ACGME regulations.

The Accreditation Council for Graduate Medical Education Duty Hour Regulations How Do We Make the Best of an Unpopular Situation in Training the Surgeons of Tomorrow? Making the Best of an Unpopular Situation

Kirton OC. — Wed, 01 May 2013 00:00:00 GMT

In 2003, the Accreditation Council for Graduate Medical Education (ACGME) established the hour limits for postgraduate residency training programs based on an 80-hour work week, 1 day off in 7, a maximum shift length of 24 hours with 6 hours of care continuity, and overnight call coverage no more frequent than every third night. In 2011, the ACGME further restricted duty hours, with interns limited to 16-hour duty shifts, coupled with tighter junior resident supervision rules and further reduction of duty continuity to 4 hours (after a shift length of 24 hours).

The Out-of-Circuit Rectum in Ulcerative Colitis: The Bumpy Road Less Traveled Comment on “ Fate of Rectal Stump After Subtotal Colectomy for Ulcerative Colitis in the Era of Ileal Pouch–Anal Anastomosis” Out-of-Circuit Rectum in Ulcerative Colitis

Longo WE. — Wed, 01 May 2013 00:00:00 GMT

Historically, subtotal colectomy has been one option for patients requiring surgery for ulcerative colitis. It is performed in severely ill patients who are uncertain of their diagnosis or desire to have this procedure. At a future date, patients may undergo a completion proctectomy with an ileoanal anastomosis, a proctectomy with an end ileostomy, or, exceedingly rarely, an ileorectal anastomosis. However, a cohort of patients continue to retain their rectal stump for a significant period for a variety of reasons, including but not limited to health-related reasons, caution regarding impotence until childbearing years have passed, concerns about the functional results of a restorative procedure, or the fear of an eventually permanent stoma. On the other hand, concerns about cancer in the retained rectal stump, continued symptoms from the retained rectum, and the need for continued surveillance of the rectal stump all preoccupy both the patient and the physician in optimizing the patient's care. Decision making among patients with a retained rectum following subtotal colectomy may be problematic, and the best option may be delayed for the heretofore listed reasons as well as loss of patient follow-up.

The Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) A Nationwide Registry for Quality Assurance of Gallstone Surgery Swedish Registry of Gallstone Surgery and ERCP

Enochsson L, Thulin A, Österberg J, et al. — Wed, 01 May 2013 00:00:00 GMT

Objectives

To describe the process of initiating and organizing a nationwide validated web-based quality registry of gallstone surgery and endoscopic retrograde cholangiopancreatography (ERCP) and to present some clinical data and the impact the registry has had on the clinical treatment of gallstones.

Design

Observational, population-based registry study.

Setting

Data from the nationwide Swedish Registry of Gallstone Surgery and ERCP (GallRiks).

Patients

From May 1, 2005, to December 31, 2011, 63 685 cholecystectomies (laparoscopic and open) and 37 860 ERCPs have been prospectively registered in GallRiks.

Interventions

Cholecystectomies, laparoscopic or conventional, as well as ERCP in a population-based setting.

Main Outcome Measures

Registrations of all cholecystectomies and ERCPs are performed online by the surgeon or endoscopist. Thirty-day follow-up of both gallstone surgery and ERCP is mandatory, as is an additional 6-month follow-up of the cholecystectomies. Scores on the 36-Item Short Form Health Survey are registered preoperatively and 6 months postoperatively in elective cholecystectomies at selected units.

Results

The 30-day overall complication rate is 6.1% in elective cholecystectomy, 11.2% in urgent cholecystectomy, and 12.0% following ERCP. The use of antibiotic and thromboembolic prophylaxis in elective laparoscopic cholecystectomy in Sweden has decreased by 8.7% and 17.8% (2006-2011), respectively, mainly owing to presentation of GallRiks data both at meetings and published in peer-reviewed publications. The large database has also enabled several research projects, including one demonstrating that the intention to perform intraoperative cholangiography reduced the risk of death after cholecystectomy. The database has reached greater than 90% national coverage and is continuously validated.

Conclusions

GallRiks is a validated national quality registry for gallstone surgery and ERCP, serving as a base for audit of gallstone disease treatment. It also provides a database for clinical research.

Transvaginal Cholecystectomy: Does a Go From Below Halt the Thunder Down Under? Comment on “Transvaginal Cholecystectomy” Transvaginal Cholecystectomy

Gass JS. — Wed, 01 May 2013 00:00:00 GMT

Natural orifice transluminal endoscopic surgery capitalizes on the body's established passageways as routes for surgical organ manipulation. Intuitively using a patent avenue to approach disease ought to incur fewer of the perpetual surgical complications of infection, bleeding, and pain. Minimal access surgeons have used natural cavities as arenas for surgical manipulation, although they require entry through the skin and muscular wall. While incisions are small, 5 to 10 mm, they cause pain and have the attendant risks of surgery, including that of postoperative hernia. To move beyond these hurdles, natural orifice transluminal endoscopic surgery has been used for entry into the peritoneum. Work by Solomon et al suggests that while the operative time may be longer with the transvaginal approach for cholecystectomy, postoperative pain in particular is less. The challenge seems to be convincing the patients, given perceptions of complications, sexual function, and fertility, with only 41% of women considering the transvaginal approach as an option for cholecystectomy in a recent Mayo Clinic survey of 409 women. These patients voiced fear of complications, pain, infection, and recovery time and concern for the technical aspect of the approach, while in the current studies the concerns related to sexuality, especially in younger women.

Transvaginal Cholecystectomy Effect on Quality of Life and Female Sexual Function Transvaginal Cholecystectomy

Wood SG, Solomon D, Panait L, et al. — Wed, 01 May 2013 00:00:00 GMT

Importance

Transvaginal cholecystectomy (TVC) is the leading natural orifice transluminal endoscopic surgery to date and has the potential to offer improved cosmesis, less pain, and shorter recovery times for female patients.

Objective

To investigate quality of life and female sexual function in our patients undergoing TVC.

Design

A prospective cohort study from August 14, 2009, to June 12, 2012, of TVCs performed at our institution to date.

Setting

Tertiary academic referral center.

Participants

The first 47 consecutive female patients (aged 18-65 years) who received a TVC by a single surgeon.

Interventions

A hybrid TVC was performed by a 5-mm umbilical trocar and a 12-mm transvaginal trocar with standard laparoscopic instruments.

Main Outcomes and Measures

Quality-of-life index (36-Item Short Form Health Survey) and female sexual function (Female Sexual Function Index) scores.

Results

A total of 47 TVCs were performed, with a mean age of 39 years, mean body mass index (calculated as weight in kilograms divided by height in meters squared) of 31, and mean operative time of 65 minutes. No difference was noted in overall female sexual function from preoperatively to 1 and 3 months postoperatively. When comparing quality of life preoperatively vs 1 and 3 months postoperatively, there were significant improvements in physical function (P = .02), energy and fatigue (P = .001), emotional well-being (P = .01), pain (P < .001), and general health (P = .03). No significant changes were noted in physical limitations (P = .18), emotional problems (P = .72), and social function (P = .12).

Conclusions and Relevance

In our experience to date, female sexual function is unchanged and quality of life either is unchanged or improves at 1 and 3 months following TVC. Undergoing TVC does not appear to negatively affect female sexual function or quality of life in the short term.

Traumatic Injuries in Developing Countries Report From a Nationwide Cross-Sectional Survey of Sierra Leone Traumatic Injuries in Developing Countries

Stewart KA, Groen RS, Kamara TB, et al. — Wed, 01 May 2013 00:00:00 GMT

Objective

To use a nationwide household survey tool to provide an estimate of injury prevalence, mechanisms of traumatic injuries, and number of injury-related deaths in a low-income country.

Design

A randomized, cross-sectional nationwide survey using the Surgeons OverSeas Assessment of Surgical Need tool was conducted in 2012.

Setting

Sierra Leone, Africa.

Participants

Three thousand seven hundred fifty randomly selected participants throughout Sierra Leone.

Main Outcome Measures

Mechanisms of injury based on age, sex, anatomic location, cause, and sociodemographic factors as well as mechanisms of injury-related deaths in the previous year were the primary outcome measures.

Results

Data were collected and analyzed from 1843 households and 3645 respondents (98% response rate). Four hundred fifty-two respondents (12%) reported at least 1 traumatic injury in the preceding year. Falls were the most common cause of nonfatal injuries (40%). The extremities were the most common injury site regardless of age or sex. Traffic injuries were the leading cause of injury-related deaths (32% of fatal injuries).

Conclusions

This study provides baseline data on the mechanisms of traumatic injuries as well as the sociodemographic factors affecting injury prevalence in one of the world's poorest nations. It is anticipated that these data will provide an impetus for further studies to determine injury severity, associated disability, and barriers to accessing care in these resource-poor areas.