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Liane S Feldman

Publications and source records attributed to Liane S Feldman.

13 recordsLinked to original sources
PubMed2006

Effect of pneumoperitoneum on renal perfusion and function: a systematic review.

BACKGROUND: The precise physiologic consequences of insufflating carbon dioxide into the abdominal cavity during laparoscopy are not yet fully understood. This systematic review aimed to investigate whether pneumoperitoneum results in decreased renal blood flow (RBF) or renal function. METHODS: A literature search was conducted electronically using Medline, Embase, and the Cochrane libraries on 1 July 2005. Various combinations of the medical subject headings--renal blood flow, pneumoperitoneum, renal function, and laparoscopy--were searched in all three databases. Reference lists from articles fulfilling the search criteria were used to identify additional articles. RESULTS: The literature search retrieved 20 articles concerning RBF and 25 articles concerning renal function during pneumoperitoneum. It was found that 17 of the 20 studies identified a decrease in RBF, and 20 of the 25 studies identified a decrease in renal function during pneumoperitoneum. CONCLUSION: There appears to be sufficient evidence to conclude that both renal function and RBF are decreased during pneumoperitoneum. The magnitude of the decrease is dependent on factors such as preoperative renal function, level of hydration, level of pneumoperitoneum, patient positioning, and duration of pneumoperitoneum.

Animals↗
PubMed2006

Elucidating the relationship between cardiac preload and renal perfusion under pneumoperitoneum.

INTRODUCTION: Pneumoperitoneum 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. METHODS: Eleven 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. RESULTS: LVEDD 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). CONCLUSIONS: While 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.

Animals↗
PubMed2006

Patient perception of a clinical pathway for laparoscopic foregut surgery.

Clinical pathways have been implemented for a number of surgical procedures, yet few data are available that explore the patients' perception of these changes in clinical practice. A clinical pathway was developed for laparoscopic fundoplication, Heller myotomy, and paraesophageal hernia repair. Data collected from a cohort of patients undergoing surgery with the pathway over a 12-month period was compared with a group of patients operated on in the 12 months prior to pathway implementation. A questionnaire examining patient-based outcomes and perceptions was completed 6 weeks after surgery. From November 2001 through November 2003, 49 patients underwent primary laparoscopic foregut surgery, 27 before and 22 after pathway implementation. There were no differences in age, gender, procedure, or ASA Class. Parenteral opioid use diminished significantly without compromising the patients' perceived pain control. The number of patients undergoing postoperative investigations diminished, as did length of stay. Of the 20 post-pathway patients completing satisfaction questionnaires, 95% were satisfied or very satisfied with their care during admission. Pathway implementation resulted in a significant reduction in direct postoperative hospital costs. A clinical pathway for laparoscopic foregut surgery was successfully implemented in a single-payer system, resulting in decreased utilization of hospital resources while maintaining high patient satisfaction.

Adult↗
PubMed2006

Evaluating surgical outcomes.

The study of outcomes has become essential for guiding quality of-care assessment and for clinical research. In this article, the properties and process of patient outcomes measurement are described. The limitations of traditional outcomes are discussed and contrasted with the emerging concept of "patient-centered"outcomes, measured by validated instruments to assess the effects of surgical interventions on health-related quality of life, functional status, pain, and patient satisfaction. The strengths and weaknesses of several measurement tools used in the surgical literature are evaluated. Finally, the authors introduce "composite outcomes" as a reflection of the multidimensional nature of modern patient care.

Employment↗
PubMed2005

A global assessment tool for evaluation of intraoperative laparoscopic skills.

BACKGROUND: There is a pressing need for an intraoperative assessment tool that meets high standards of reliability and validity to use as an outcome measure for different training strategies. The aim of this study was to develop a tool specific for laparoscopic skills and to evaluate its reliability and validity. METHODS: The Global Operative Assessment of Laparoscopic Skills (GOALS) consists of a 5-item global rating scale. A 10-item checklist and 2 visual analogue scales (VAS) for competence and case difficulty were also used. During laparoscopic cholecystectomy, 21 participants were evaluated by the attending surgeon, by 2 trained observers and by self-assessment while dissecting the gallbladder from the liver bed. RESULTS: The intraclass correlation coefficient (ICC) for the total GOALS score was .89 (95% confidence interval [CI] .74 to .95) between observers, .82 (95% CI .67 to .92) between observers and attending surgeons, and .70 (95% CI .37 to .87) between participants and attending surgeons. The ICCs (observers) for the VAS (competence) and the checklist were .69 and .70, respectively. The mean total GOALS score (observers) for novices (postgraduate years [PGYs] 1 through 3) was 13 (95% CI 10.3 to 15.7) compared with 19.4 (95% CI 17.2 to 21.5) for experienced (PGY 4 through attending surgeons, P = .0006). The VAS demonstrated a difference in scores between novice and experienced participants (P = .001); however, the task checklist did not (P = .09). CONCLUSIONS: These data indicate that GOALS is feasible, reliable, and valid. They also suggest that it is superior to the task checklist and VAS for evaluation of technical skill by experienced raters. The findings support the use of GOALS in the training and evaluation of laparoscopic skills.

Clinical Competence↗
PubMed2005

Validity of the MISTELS simulator for laparoscopy training in urology.

BACKGROUND AND PURPOSE: The McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) consists of a series of five laparoscopic exercises performed in an endotrainer box. MISTELS has been validated for use in both training and evaluation of general surgery residents in fundamental laparoscopic skills. The purpose of this study was to demonstrate the construct validity of MISTELS for urology residents. SUBJECTS AND METHODS: Seventeen participants were evaluated during performance of the five MISTELS tasks (peg transfer, pattern cutting, ligating loop, and suturing with extracorporeal and intracorporeal knots) using the standardized scoring system, which rewards both speed and precision. Participants included 13 urology residents (PGY 1-5), 1 fellow, and 3 urologists experienced in laparoscopy. Results are expressed as median (range). The Mann-Whitney U-test was used to compare MISTELS scores for 9 novice (PGY 1-4) and 8 experienced urologists (PGY 5-attending). P < 0.05 was considered statistically significant. RESULTS: The median MISTELS total normalized score for novices was 52.3 (range 15-68.9) compared with 71.7 (range 56.3-82.9) for experienced urologists (P = 0.007). Although the experienced group achieved higher scores in all five individual tasks, statistically significant differences were demonstrated for the peg transfer and intracorporeal suture tasks only. CONCLUSION: These data provide evidence for construct validity of the MISTELS system for urology residents.

Education, Medical, Graduate↗
PubMed2005

Measuring surgical recovery: the study of laparoscopic live donor nephrectomy.

Following laparoscopic donor nephrectomy (LDN), recovery has only been studied using traditional outcomes, subjective and confounded by comorbidity and psychosocial variables. The purpose of this study is to estimate surgical recovery following LDN using standardized, validated instruments and to compare this recovery profile to that obtained with traditional measures. This was a prospective study of patients undergoing LDN at a single institution between September 2001 and January 2004 (n = 35). At baseline and 4 weeks following surgery, functional exercise capacity was measured using the 6-min walk test (6MWT) and health-related quality of life was assessed with the Short Form-36 (SF-36) questionnaire, including physical component summary (PCS) and mental component summary (MCS) scores. Patients' self-assessment of recovery and time to resumption of regular activities was ascertained. At follow-up (median 29 days), patients' 6MWT was lower by a median of 30 m (p = 0.07) and PCS decreased from 57.1 to 42.3 (p = 0.0001), whereas MCS remained constant. Overall, length of stay, return to activities and patient-stated recovery were inadequate outcomes for classifying patient recovery using 6MWT and PCS as the reference standards. Four weeks following LLDN, patients have returned to baseline exercise capacity, but not baseline general physical health. Traditional measures of recovery are incomplete descriptors of recovery.

Adult↗
PubMed2005

Has the introduction of laparoscopic Heller myotomy altered the treatment paradigm of achalasia?

Although surgical myotomy is well established as the most effective and durable treatment for achalasia, wide acceptance of this procedure as a first-line treatment has been hampered by perceived invasiveness and morbidity. Laparoscopic myotomy has significantly reduced surgical trauma and morbidity while maintaining effectiveness. The effect of laparoscopic myotomy on the treatment pattern for achalasia is not currently known. All patients undergoing surgical myotomy in Quebec from 1997 to 2002 were identified from the Régie de l'assurance maladie du Québec billing database; previous endoscopic treatment was documented from 1990 to the time of surgery. Patients were divided into two groups (prelaparoscopy and postlaparoscopy) defined by the approximate date when laparoscopic myotomy became generally available in Quebec. A questionnaire examining treatment preference for achalasia was sent to all Quebec gastroenterologists. The number of myotomies performed in Quebec remained stable (prelaparoscopy = 28.7/year; postlaparoscopy = 33/year), but were performed on an older population. The rate of preoperative endoscopic treatment did not differ from prelaparoscopy (29.2%) to postlaparoscopy (23.3%). However, the time interval between the last endoscopy and myotomy diminished significantly. Questionnaire response rate was 41% (60 of 147). Although myotomy was recognized as the most effective treatment (54 of 60), only 22 of 60 gastroenterologists would refer a healthy patient for myotomy as initial treatment. Other choices included dilation (33 of 60), Botulinum toxin (two of 60) or calcium channel blockade (three of 60). Despite a decrease in time interval between endoscopic treatment and surgery, no decrease in the rate of existing endoscopic therapies occurred after laparoscopic myotomy became widely available. The benefits and minimal risks associated with laparoscopic myotomy need to be more effectively communicated by referring physicians.

Adolescent↗
PubMed2004

Relationship between objective assessment of technical skills and subjective in-training evaluations in surgical residents.

BACKGROUND: Technical skills of residents have traditionally been evaluated using subjective In-Training Evaluation Reports (ITERs). We have developed the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS), an objective measure of laparoscopic technical ability. The purpose of the study was to assess the concurrent validity of the MISTELS by exploring the relationship between MISTELS score and ITER assessment. STUDY DESIGN: Fifty surgery residents were assessed on the MISTELS system. Concurrent ITER assessments of technical skill were collected, and the proportion of superior ratings for the year was calculated. Statistical comparisons were performed by ANOVA and chi-square analysis. The Pearson correlation coefficient was used to compare the scores in the MISTELS with the ITER ratings. RESULTS: The 50 residents received 277 ITERs for the year, of which 103 (37%) were "superior," 170 (61%) "satisfactory," 4 (1%) "borderline," and 0 "unsatisfactory." The MISTELS score correlated moderately well with the proportion of superior ITER scores (r = 0.51, p < 0.01). Residents who passed the MISTELS had a higher proportion of superior ITER assessments than those who failed the MISTELS (p = 0.02), but residents who performed below their expected level on the MISTELS still received mainly satisfactory ITERs (82 +/- 18%). CONCLUSIONS: The ITER assessment is poor at identifying residents with below-average technical skills. Residents who perform well in the MISTELS laparoscopic simulator also have better ITER evaluations, providing evidence for the concurrent validity of the MISTELS. Multiple assessment instruments are recommended for assessment of technical competency.

Clinical Competence↗
PubMed2004

Proving the value of simulation in laparoscopic surgery.

OBJECTIVE: To assess the McGill Inanimate System for Training and Evaluation of Laparoscopic Skills (MISTELS) physical laparoscopic simulator for construct and predictive validity and for its educational utility. SUMMARY BACKGROUND DATA: MISTELS is the physical simulator incorporated by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in their Fundamentals of Laparoscopic Surgery (FLS) program. MISTELS' metrics have been shown to have high interrater and test-retest reliability and to correlate with skill in animal surgery. METHODS: Over 200 surgeons and trainees from 5 countries were assessed using MISTELS in a series of experiments to assess the validity of the system and to evaluate whether practicing MISTELS basic skills (transferring) would result in skill acquisition transferable to complex laparoscopic tasks (suturing). RESULTS: Face validity was confirmed through questioning 44 experienced laparoscopic surgeons using global rating scales. MISTELS scores increased progressively with increasing laparoscopic experience (n = 215, P < 0.0001), and residents followed over time improved their scores (n = 24, P < 0.0001), evidence of construct validity. Results in the host institution did not differ from 5 beta sites (n = 215, external validity). MISTELS scores correlated with a highly reliable validated intraoperative rating of technical skill during laparoscopic cholecystectomy (n = 19, r = 0.81, P < 0.0004; concurrent validity). Novice laparoscopists were randomized to practice/no practice of the transfer drill for 4 weeks. Improvement in intracorporeal suturing skill was significantly related to practice but not to baseline ability, career goals, or gender (P < 0.001). CONCLUSION: MISTELS is a practical and inexpensive inanimate system developed to teach and measure technical skills in laparoscopy. This system is reliable, valid, and a useful educational tool.

Clinical Competence↗
PubMed2002

Causes of increased length of hospitalization on a general thoracic surgery service: a prospective observational study.

OBJECTIVE: To characterize medical and nonmedical reasons for delayed discharge on a general thoracic surgery unit. DESIGN: A prospective observational cohort study. SETTING: A university-affiliated tertiary care institution. PATIENTS: Between February 1999 and July 2000, the in-hospital progress of 130 patients who had undergone an elective thoracic surgical procedure was evaluated prospectively. Baseline characteristics (age, sex, comorbid conditions and pulmonary function test results) were documented. MAIN OUTCOME MEASURES: Complications that delayed the time when the patient was medically ready for discharge. The day the patient was deemed fit for discharge (medically required length of stay) was compared with the actual day of discharge (actual length of stay). RESULTS: The 3 most frequent complications that prevented discharge by postoperative day 6 were persistent air leaks, pulmonary infections and atrial fibrillation. The presence of a persistent air leak increased the medically required length of stay by a mean of 13.1 days (95% confidence interval [CI] 11.0-15.2 d), pneumonia by 9.6 days (95% CI 4.96-14.2 d) and atrial fibrillation by 2.4 days (95% CI -2.6 to 7.4 d). The mean medically required length of stay was 6.9 days, and this differed from the mean day on which the patient was actually discharged (7.35 d, p < 0.01), which contributed 44 excess days of hospitalization per 100 patients. The 2 most common causes of this discrepancy were the lack of home support (10.2% of patients) and the unavailability of convalescent facilities (7.1% of patients). Prolonged hospital stay for nonmedical reasons was associated with increased mean age (67.4 v. 60.7 yr, p = 0.05). CONCLUSIONS: Length of hospitalization after elective thoracic surgery may be prolonged for medical or nonmedical reasons. Although complications like persistent air leak and pneumonia have an impact on medically required length of stay, social factors may also significantly delay discharge.

Aftercare↗