Background In 2006, we reported results of a randomized trial of laparoscopic paraesophageal hernia repair (LPEHR), comparing primary diaphragm repair (PR) with primary repair buttressed with a ...biologic prosthesis (small intestinal submucosa SIS). The primary endpoint, radiologic hiatal hernia (HH) recurrence, was higher with PR (24%) than with SIS buttressed repair (9%) after 6 months. The second phase of this trial was designed to determine the long-term durability of biologic mesh-buttressed repair. Methods We systematically searched for the 108 patients in phase I of this study to assess current clinical symptoms, quality of life (QOL) and determine ongoing durability of the repair by obtaining a follow-up upper gastrointestinal series (UGI) read by 2 radiologists blinded to treatment received. HH recurrence was defined as the greatest measured vertical height of stomach being at least 2 cm above the diaphragm. Results At median follow-up of 58 months (range 42 to 78 mo), 10 patients had died, 26 patients were not found, 72 completed clinical follow-up (PR, n = 39; SIS, n = 33), and 60 repeated a UGI (PR, n = 34; SIS, n = 26). There were 20 patients (59%) with recurrent HH in the PR group and 14 patients (54%) with recurrent HH in the SIS group (p = 0.7). There was no statistically significant difference in relevant symptoms or QOL between patients undergoing PR and SIS buttressed repair. There were no strictures, erosions, dysphagia, or other complications related to the use of SIS mesh. Conclusions LPEHR results in long and durable relief of symptoms and improvement in QOL with PR or SIS. There does not appear to be a higher rate of complications or side effects with biologic mesh, but its benefit in reducing HH recurrence diminishes at long-term follow-up (more than 5 years postoperatively) or earlier.
Less than complete cholecystectomy has been advocated for difficult operative conditions for more than 100 years. These operations are called partial or subtotal cholecystectomy, but the terms are ...poorly defined and do not stipulate whether a remnant gallbladder is created. This article briefly reviews the history and development of the procedures and introduces new terms to clarify the field. The term partial is discarded, and subtotal cholecystectomies are divided into “fenestrating” and “reconstituting” types. Subtotal reconstituting cholecystectomy closes off the lower end of the gallbladder, reducing the incidence of postoperative fistula, but creates a remnant gallbladder, which may result in recurrence of symptomatic cholecystolithiasis. Subtotal fenestrating cholecystectomy does not occlude the gallbladder, but may suture the cystic duct internally. It has a higher incidence of postoperative biliary fistula, but does not appear to be associated with recurrent cholecystolithiasis. Laparoscopic subtotal cholecystectomy has advantages but may require advanced laparoscopic skills.
Safety First, Total Cholecystectomy Second Pucci, Michael J., MD, FACS; Brunt, L. Michael, MD, FACS; Deziel, Daniel J., MD, FACS
Journal of the American College of Surgeons,
09/2016, Letnik:
223, Številka:
3
Journal Article
Background Skills training plays an increasing role in residency training. Few medical schools have skills courses for senior students entering surgical residency. Methods A skills course for 4th ...-year medical students matched in a surgical specialty was conducted in 2006 and 2007 during 7 weekly 3-hour sessions. Topics included suturing, knot tying, procedural skills (eg, chest tube insertion), laparoscopic skills, use of energy devices, and on-call management problems. Materials for outside practice were provided. Pre- and postcourse assessment of suturing skills was performed; laparoscopic skills were assessed postcourse using the Society of American Gastrointestinal and Endoscopic Surgeons' Fundamentals of Laparoscopic Surgery program. Students' perceived preparedness for internship was assessed by survey (1 to 5 Likert scale). Data are mean ± SD and statistical analyses were performed. Results Thirty-one 4th -year students were enrolled. Pre- versus postcourse surveys of 45 domains related to acute patient management and technical and procedural skills indicated an improved perception of preparedness for internship overall (mean pre versus post) for 28 questions (p < 0.05). Students rated course relevance as “highly useful” (4.8 ± 0.5) and their ability to complete skills as “markedly improved” (4.5 ± 0.6). Suturing and knot-tying skills showed substantial time improvement pre- versus postcourse for 4 of 5 tasks: simple interrupted suturing (283 ± 73 versus 243 ± 52 seconds), subcuticular suturing (385 ± 132 versus 274 ± 80 seconds), 1-handed knot tying (73 ± 33 versus 58 ± 22 seconds), and tying in a restricted space (54 ± 18 versus 44 ± 16 seconds) (p < 0.02). Only 2-handed knot tying did not change substantially (65 ± 24 versus 59 ± 24 seconds). Of 13 students who took the Fundamentals of Laparoscopic Surgery skills test, 5 passed all 5 components and 3 passed 4 of 5 components. Conclusions Skills instruction for senior students entering surgical internship results in a higher perception of preparedness and improved skills performance. Medical schools should consider integrating skills courses into the 4th -year curriculum to better prepare students for surgical residency.
Abstract We sought to determine the feasibility of developing a multimedia educational tutorial to teach learners to assess the critical view of safety using input from expert surgeons, non-surgeons ...and crowd-sourcing. We intended to develop a tutorial that would teach learners how to identify the basic anatomy and physiology of the gallbladder, identify the components of the critical view of safety criteria, and understand its significance for performing a safe gallbladder removal. Using rounds of assessment with experts, laypersons and crowd-workers we developed an educational video with improving comprehension after each round of revision. We demonstrate that the development of a multimedia educational tool to educate learners of various backgrounds is feasible using an iterative review process that incorporates the input of experts and crowd sourcing. When planning the development of an educational tutorial, a step-wise approach as described herein should be considered.
Reply Oelschlager, Brant K., MD, FACS; Pellegrini, Carlos A., MD, FACS; Mitsumori, Lee M., MD ...
Journal of the American College of Surgeons,
2012, Letnik:
215, Številka:
1
Journal Article
Reply Brunt, L. Michael, MD, FACS; Strasberg, Steven M., MD, FACS
Journal of the American College of Surgeons,
2011, Letnik:
212, Številka:
3
Journal Article
Reply Strasberg, Steven M., MD, FACS; Brunt, L. Michael, MD, FACS
Journal of the American College of Surgeons,
2010, Letnik:
211, Številka:
5
Journal Article
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