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Mary E Klingensmith

Publications and source records attributed to Mary E Klingensmith.

15 recordsLinked to original sources
PubMed2006

Outcomes of laparoscopic paraesophageal hernia repair in elderly and high-risk patients.

BACKGROUND: This study examines the impact of age and comorbidities on complications and outcomes of laparoscopic (Lap) paraesophageal hernia (PEH) repair. METHODS: Data were collected prospectively on all patients who underwent Lap PEH repair from January 1995 through June 2005. Pre- and postoperative variables including complications were analyzed. Patients were stratified by age (Group [Gr.] 1, <65 years; Gr. 2, 65 to 74 years; Gr. 3, >/=75 years) and American Society of Anesthesiology (ASA) class (1 and 2 vs 3 and 4). Statistical analysis was performed using 1-way ANOVA, chi-square, and Fisher exact test. RESULTS: Overall, 171 patients underwent Lap PEH repair. Mean patient age was 65 +/- 15 years, mean ASA class 2.4 +/- 0.5, gender 72% female, and mean operating time 173 +/- 49 min. Patients in Gr. 3 had a significantly higher ASA class (Gr. 1, 2.3 +/- 0.6; Gr. 2, 2.5 +/- 0.5; Gr. 3, 2.6 +/- 0.5) and longer postoperative length of stay (LOS) compared with Gr. 1 (P < 0.05). Esophageal lengthening was required in 10.4% of patients in Gr. 3 versus 2.6% in Gr. 1 and 2.1% in Gr. 2 (P = 0.079). Total complication rates were 17.1% in Gr. 1, 22.4% in Gr. 2, and 27.7% in Gr. 3 (P = not significant [NS]). Most complications were minor; grade 2 or higher complications occurred in 10.5% of patients in Gr. 1, 8.3% in Gr. 2, and 8.5% in Gr. 3 (P = NS). There was 1 death (Gr. 2) on postoperative day 18 due to a myocardial infarction (mortality rate = 0.6%). Mean follow-up was 25.3 +/- 20.6 months. Postoperative symptoms of heartburn and regurgitation were similar between groups as was antisecretory medication use. Anatomic failure of the repair occurred in 23.7% of patients with adequate follow-up: 26.7% in Gr. 1, 15.4% in Gr. 2, and 27.8% in Gr. 3 (P = NS). Reoperation was performed in 1 of 32 (3.1%) failures. CONCLUSIONS: Lap PEH repair is safe in elderly and properly selected high-risk patients, although complication rates are higher than in younger patients. Most patients have a good symptomatic outcome irrespective of their age, but the anatomic recurrence rates remain a concern for all age groups.

Adult↗
PubMed2006

Who are our future surgeons? Characteristics of medical school graduates planning surgical careers: analysis of the 1997 to 2004 Association of American Medical Colleges' Graduation Questionnaire National Database.

BACKGROUND: Identification of correlates of contemporary US medical graduates' surgical career plans can provide insights about the emerging surgical workforce composition and inform future recruitment efforts. STUDY DESIGN: We analyzed individualized records of 95,176 graduates who completed the 1997 to 2004 Association of American Medical Colleges Graduation Questionnaire for associations between planning a general-surgery or a surgical-specialty (orthopaedic surgery, neurologic surgery, plastic surgery, urology, or otolaryngology) career and a set of medical-school experience, professional-setting preference, and demographic variables. RESULTS: Graduates who reported better quality of their surgery clerkship experience and career-setting preference of "university faculty" compared with "nonuniversity clinical practice" were more likely to plan general-surgery or surgical-specialty careers compared with nonsurgical careers (each p < 0.001). Women and graduates from combined MD/PhD programs and those who planned to practice in underserved areas were less likely to plan general-surgery or surgical-specialty careers compared with nonsurgical careers (each p < 0.001). Graduates of nonwhite race or ethnicity and from combined MD/other-degree (non-PhD) programs were more likely to plan general-surgery careers (p < 0.001). Compared with 1997 graduates, 1998 to 2004 graduates were less likely to plan general-surgery careers than surgical-specialty careers (each p < or = 0.001), and 1999 to 2004 graduates were more likely to plan surgical-specialty careers than nonsurgical careers (each p < or = 0.006). CONCLUSIONS: Contemporary graduates planning surgical careers represent a relatively narrow spectrum of US medical graduates, and those planning general-surgery careers differ in numerous ways from those planning surgical-specialty careers. Targeted efforts are warranted to recruit US medical graduates qualified to meet the nation's future health-care needs and advance the profession of surgery.

Career Choice↗
PubMed2006

Educational scholarship as a route to academic promotion: a depiction of surgical education scholars.

BACKGROUND: Education is the central component of academic medicine. Historically, academic promotion has favored clinician-investigators over clinician-educators. However, there are increasing numbers of individuals pursuing education scholarship as their academic focus. This study sought to describe these individuals and their experiences with academic promotion. METHODS: A cross-sectional survey of surgical educators was undertaken, eliciting demographic data and attitudes toward educational efforts and promotion. RESULTS: Advanced academic rank was associated with male gender, age, publication on education topics, funding for research in education, recipient of teaching awards, and status as officer in an education association. CONCLUSIONS: Educational scholarship is a viable pathway for academic promotion when sentinel components are included.

Adult↗
PubMed2006

Laparoscopy as an educational and recruiting tool.

BACKGROUND: General surgeons can supplement traditional gross anatomy instruction by using laparoscopy to provide clinical correlations. Early, positive interaction with surgeons may stimulate student interest in this field. METHODS: Basic laparoscopy was performed on fresh cadavers for first year medical students in gross anatomy over 2 consecutive years. Surgical residents reviewed anatomy of the abdomen, and students manipulated intra-abdominal organs using laparoscopic instruments. Students completed pre- and post-demonstration questionnaires that were compared independently. RESULTS: More than 95% of responding students agreed the demonstration enhanced their understanding of abdominal anatomy. Regardless of planned area of specialization, students felt the demonstration reinforced the clinical relevance of gross anatomy. Among students already anticipating surgical careers, 88.2% said the demonstration increased their interest in general surgery; this was significantly higher than among those intending careers in internal medicine (27.3%) or other fields (23.5%; P < .0001). CONCLUSIONS: Cadaver-based laparoscopy demonstrations by general surgeons supplement didactic sessions and enhance learning in gross anatomy. Furthermore, such demonstrations may stimulate student interest in general surgery at an early point in their medical education, particularly in those already interested in a surgical career.

Abdomen↗
PubMed2005

Perioperative outcomes and complications of laparoscopic ventral hernia repair.

BACKGROUND: Laparoscopic techniques are being used increasingly in the repair of ventral hernias and offer the potential benefits of a shorter hospital stay, decreased wound complications, and possibly a lower recurrence rate. Despite good results from high-volume centers, significant complications may occur with this approach and the morbidity of incisional hernia repair may be underestimated. The purpose of this study was to review our experience with laparoscopic ventral hernia repair (LVHR) since its inception at our institution. METHODS: Medical records of all patients who underwent LVHR at a single institution from May 2000 through December 2003 were reviewed. Preoperative and postoperative variables including complications were analyzed. Follow-up evaluation was by office visit and phone survey with assessment of patient satisfaction scores. Data are expressed as mean +/- SD. RESULTS: A total of 121 LVHR were performed in 116 patients (52 men, 64 women; mean age, 57 +/- 13 y; mean body mass index, 35 +/- 8). Hernias were recurrent in 35 cases (28.9%), with a mean of 1.4 prior repairs (range, 1-7). The mean defect size was 109 +/- 126 cm2 and the average mesh size used was 256 +/- 192 cm2. Operating time was 147 +/- 45 minutes, and the hospital stay averaged 1.7 +/- 1 days. Twelve cases (9.9%) were converted to open operation, most commonly because of extensive adhesions. Extensive laparoscopic adhesiolysis was necessary in 29 cases (26.6%). Overall, perioperative complications occurred in 33 cases (27.3%), 13 of which (39.3%) were persistent seromas. Major complications were seen in 9 cases (7.4%). There were 4 enterotomies (3.3%): 3 occurred as a result of adhesiolysis and 1 resulted from a trocar injury; 2 were detected intraoperatively and were converted to open operation and 2 presented postoperatively. One of these patients developed sepsis and died. Follow-up evaluation was available for 83.6% of cases at a mean interval of 22 +/- 16 months after repair. The hernia recurrence rate was 9.3% (9 cases) and was detected at a median of 6 months postoperatively. The overall patient satisfaction score was high at 4.3 +/- 1.1 (scale, 1-5). CONCLUSIONS: Laparoscopic repair is effective for the vast majority of patients with primary or recurrent ventral hernias and results in hernia recurrence rates of less than 10%, with high patient satisfaction scores. Although seroma is the most common complication, major morbidity occurred in 7.4% of the patients in our series. Enterotomy is the most common serious complication and may result in sepsis and death.

Adult↗
PubMed2004

Surgeon workhours in the era of limited resident workhours.

BACKGROUND: Resident workhours have received much attention, yet there is little information concerning faculty workhours. In addition, the perspectives of surgical faculty on the anticipated effects of reducing resident hours have not been studied. STUDY DESIGN: An anonymous survey was distributed to all clinical faculty in the Departments of Surgery, Neurosurgery, Orthopaedics, and Otolaryngology at a single, large academic institution. Surgeons completed a detailed retrospective report of hours worked during a 1-week period. Opinions regarding resident workhour restrictions were also elicited. Chi-square or Student's t-tests were used to determine p values as appropriate, with p </= 0.05 considered significant. RESULTS: Of 120 surveys distributed, 102 (85%) were returned. Subspecialty departments comprised 51% of respondents with 49% from general surgeons. The mean number of hours worked per week by faculty was 70.4 +/- 12.5 (SD) (73.8 +/- 14.1 for general surgeons versus 67.1 +/- 9.9 for subspecialists, p = 0.006), with only 44.1% having at least 1 day per week free from clinical duties. Up to 95% of general surgeons are paged overnight at least once per week (mean 13.6 +/- 11.2 calls/week), with 73% returning from home at least once during the week (mean 1.8 +/- 1.1 returns/week). Importantly, 84% of general surgeons believe reducing resident workhours will increase faculty hours, compared with 57% of subspecialists (p = 0.004). In addition, 87% predict that reducing resident hours will compromise surgical education, with only 11% believing the benefits of hour reduction will outweigh the negatives. CONCLUSIONS: The recommended limit for resident workhours closely approximates the average number of hours worked by surgical faculty in an academic center. Despite this, significant concern exists among the majority of surgical faculty regarding the impact of resident workhour restriction, both on faculty workhours and on resident education.

Attitude of Health Personnel↗
PubMed2004

Robotics in surgery.

Explore the source record for details and available documents.

Arthroplasty, Replacement, Hip↗
PubMed2003

Laparoscopic paraesophageal hernia repair, a challenging operation: medium-term outcome of 116 patients.

Laparoscopic paraesophageal hernia repairs performed in 116 patients between 1992 and 2001 were prospectively analyzed. Perioperative outcomes were assessed and follow-up was performed under protocol. There were 85 female and 31 male patients who had a mean (+/- SD) age of 65 +/- 13 years and an American Society of Anesthesiology score of 2.3 +/- 0.6. All but two patients underwent an antireflux procedure. Gastropexy was performed in 48 patients, an esophageal lengthening procedure in six patients, and prosthetic closure of the hiatus in six patients. Major complications occurred in five patients (4.3%) with two postoperative deaths (1.7%). Mean follow-up was 30 +/- 25 months; 96 patients (83%) have been followed for more than 6 months. Among these patients, 73 (76%) are asymptomatic, 11 (11%) have mild symptoms, and 12 (13%) take antacid medications. Protocol barium esophagograms were obtained in 69% of patients at 6 to 12 months' follow-up. Recurrence of hiatal hernia was documented in 21 patients (22% overall and in 32% of those undergoing contrast studies). Reoperation has been performed in three patients (3%). When only the patients with recurrent hiatal hernias are considered, 13 (62%) are symptomatic but only six (28%) require medication for symptoms. Laparoscopic paraesophageal hernia repair is generally safe, even in this high-risk group. This study confirms a relatively high incidence of recurrent hiatal abnormalities after paraesophageal hernia repair; however, most recurrent hiatal hernias are small and only 3% have required reoperation. Protocol esophagograms detect recurrences that are minimally symptomatic. Improved techniques must be devised to improve the long-term outcomes of laparoscopic paraesophageal hernia repair.

Adult↗
PubMed2002

The effect of robotic assistance on learning curves for basic laparoscopic skills.

BACKGROUND: We hypothesized that laparoscopic tasks performed with ZEUS robotic assistance would be done with greater precision and with a different learning curve than when performed in a standard laparoscopic trainer. METHODS: Participants were divided into the surgically experienced (n = 11) and the surgically naive (n = 17). Two laparoscopic tasks (bead transfer and rope pass) were repeated for five repetitions. RESULTS: For all drills and participants, completion time and error rate decreased across the five repetitions for each platform. Precision averaged 97% for both platforms over all drills. For both groups, completion time for tasks was shorter on the laparoscopic platform. ZEUS allowed for greater consistency in performance. CONCLUSIONS: Compared with performance on a standard laparoscopic trainer, robotic assistance allows for increasing speed and consistency while maintaining precision over multiple repetitions. Understanding how robotics affects learning curves will allow for modifications in the training experience with this new technology.

Adult↗
PubMed2002

Portal vein thrombosis after splenectomy.

BACKGROUND: Portal vein thrombosis (PVT) has been described after splenectomy, but the factors associated with its development and the clinical outcomes are poorly characterized. METHODS: Case logs of four surgeons from 1996 to 2001 were retrospectively reviewed to identify cases of postsplenectomy PVT. RESULTS: Eight cases of PVT (8%) among 101 splenectomies were identified. Indications for splenectomy in patients with PVT were myeloproliferative disease (n = 4), hemolytic anemia (n = 3), and myelodysplastic disorder (n = 1). All patients had splenomegaly (mean 1698 g, range 360 to 3150 g). Among 10 patients with myeloproliferative disease (MP), 4 patients (40%) developed PVT, compared with 4 of 12 patients (25%) with hemolytic anemia. Three of 4 patients (75%) with MP disease and spleen weight greater than 3,000 g developed PVT. Five patients developed PVT despite receiving prophylactic subcutaneous heparin postoperatively. Presenting symptoms included anorexia in 7 (88%), abdominal pain in 6 (75%), and both elevated leukocyte and platelet counts in 8 patients (100%). All diagnoses were made by contrast-enhanced computed tomography scan, and anticoagulation was initiated immediately. One patient died of intraabdominal sepsis; the others are alive with no clinical sequelae at 38 months of follow-up. CONCLUSIONS: PVT is a relatively common complication of splenectomy in patients with splenomegaly. A high index of suspicion, early diagnosis by contrast-enhanced computed tomography, and prompt anticoagulation are key to a successful outcome.

Adult↗
PubMedDate not supplied

Has the 80-hour work week increased faculty hours?

OBJECTIVE: The 80-hour work week has affected not only surgical residents but also faculty. The aim of this study was to determine the effect of resident hour restrictions on faculty hours and attitudes. DESIGN: Anonymous survey. SETTING: A single, large academic medical center. PARTICIPANTS: All faculty in the Departments of Surgery, Neurosurgery, Orthopedics, and Otolaryngology. METHODS: Faculty were surveyed 6 months before and 6 months after the institution of the resident 80-hour work week. Surgeons detailed hours worked over 1 week and answered yes/no questions about changes in patient care and resident education. P values were determined by Chi-square tests or Student t-tests as appropriate. RESULTS: Of the 118 surveys distributed, 88 were returned (75%). Respondents were evenly divided between general surgeons (GS) and subspecialists (SS). Initially, 70% of faculty predicted that resident work-hour restrictions would increase faculty hours; however, only 47% of faculty felt that this had occurred. When current faculty work hours were compared with previously collected data, no differences were found. Faculty reported working an average of 69.9 +/- 12.2 hours per week this year, compared with 70.4 +/- 12.5 hours last year. When asked about the global impact of the 80-hour work week on faculty, 46% viewed the changes as harmful to the faculty. More concerning, 50% of all faculty felt the care their patients received was worse than previously, with only 2% feeling patient care had improved. This perception was significantly more common among GS faculty (70% GS vs 37% SS; p < 0.01), 94% of whom felt that the current lack of continuity compromises patient care. When the data were stratified by faculty work hours, interesting differences are seen. Of those faculty with work weeks less than 60 hours, only 6% thought the changes were harmful to patients and 64% thought resident training had suffered. In contrast, of those faculty who worked greater than 80 hours per week, 56% thought patients were harmed (p = 0.03) and 100% thought training had suffered (p < 0.01). CONCLUSIONS: Faculty work hours have not increased in the 6 months after the institution of the 80-hour resident work week. However, the majority of the faculty feels that both patient care and resident education have deteriorated.

Attitude of Health Personnel↗
PubMedDate not supplied

Diversity in general surgery: a period of progress.

OBJECTIVE: Although 1996 to 2002 was a period of declining interest in general surgery (GS) among U.S. medical students (USS), most categorical general surgery (C-GS) training positions offered in the National Residency Matching Program (NRMP) continued to fill. We measured the impact of the decreasing U.S. student applicant volume on C-GS match outcomes and GS resident workforce composition over this time period. DESIGN: Match outcomes were analyzed for 7 applicant categories. Subsequent GS resident workforce compositions were analyzed for proportions of U.S. allopathic medical school graduates (USG), osteopathic medical graduates (OMG), Canadian MG (CMG), foreign MG (FMG), female physicians, and African-American physicians. Mantel-Haenzel chi-square tests measured trends in match percentages, C-GS positions filled, and GS workforce composition. All p-values are 2-sided. RESULTS: Increasing match percentages for USS applicants (p < 0.0001) and USG (p = 0.001), with a decreasing percentage of C-GS positions filled by these applicants (p < 0.0001), were from declining applicant volumes. Increasing match percentage for non-U.S. allopathic medical applicants reflected increases in both applicant volumes and matched applicants, with an increasing percentage of C-GS positions filled by these applicants (p < 0.0001). The subsequent resident workforce included increasing proportions of FMGs and OMGs (each p < 0.001); proportions of USG MDs and CMGs decreased (p < 0.0001 and p < 0.02, respectively). Concurrently, there were increasing numbers and proportions of female physicians (p < 0.0001) and African-American physicians (p < 0.0001) in the general surgery resident workforce. CONCLUSIONS: Declining interest among U.S. students in GS has resulted in a workforce comprised of residents from a broad range of educational backgrounds, but also it has provided an opportunity for progress toward achievement of a GS resident physician workforce more equitably representative of the racial and gender composition of our society at large.

Adult↗
PubMedDate not supplied

Impact of resident duty-hour reform on faculty clinical productivity.

OBJECTIVE: Prior data have shown that resident duty-hour reform has not affected faculty work hours; yet the preservation of faculty hours may have been at the expense of productivity. We sought to examine change in clinical productivity. DESIGN: Anonymous survey and analysis of faculty relative value units (RVU) database. SETTING: A single, large academic medical center. PARTICIPANTS: All clinical faculty in the Department of Surgery. METHODS: An anonymous survey was distributed to surgical faculty 18 months after reform and compared with surveys taken before and after reform. Opinions regarding productivity and working hours were solicited. P values were determined by chi-square or Student t-tests. Relative value unit data, reflecting clinical productivity, were compared before and after reform. Regression was performed with dependent variable "lnRVU" and independent variables "calendar month," "pre/post" July 2003, and "surgeon." The coefficient on "pre/post" reflected average change in RVUs. RESULTS: A total of 49 of 73 surveys were returned (67% response). Faculty reported an average of 68.0+/-7.0 weekly work hours (p=NS compared with previous survey). In the current survey, 35% felt their overall productivity had fallen due to reform. Among these, 83% felt academic productivity had suffered, 11% were unsure, and 1 person (6%) believed academic productivity was preserved. The majority (82%) reported preserved clinical productivity, 6% reported a decrease, and 12% were unsure. Overall, 60% reported doing work previously done by residents. When RVU data were examined, the coefficient on change pre- and post-reform indicated a 5.7% increase in productivity (p=0.005). However, this effect was driven by 5 surgeons with a greater than 75% increase in productivity, all young faculty, early in practice. Excluding these, there was no significant change (0.6% increase, p=0.77). CONCLUSIONS: Faculty have preserved work hours and clinical productivity, despite a tendency to take on work previously done by residents. This suggests that academic activities may have suffered.

Academic Medical Centers↗
PubMedDate not supplied

Patients with upright reflux have less favorable postoperative outcomes after laparoscopic antireflux surgery than those with supine reflux.

The aim of this study was to compare symptomatic outcomes after laparoscopic antireflux surgery in patients with upright vs. supine reflux. A prospective database was used to assess postoperative clinical outcomes in relation to positional patterns of reflux in 117 patients. Supine reflux was present in 31%, upright in 24%, and the remaining 44% had bipositional reflux. Preoperatively there were no differences in the frequency of typical or atypical symptoms between groups. At a mean follow-up of 18 +/- 11 months postoperatively, there were marked differences in symptoms between groups. Patients with upright reflux noted significantly more heartburn, chest pain, odynophagia, and bloating postoperatively when compared to patients with supine and bipositional reflux (P < 0.05). According to visual analog scales, patients with upright reflux expressed less satisfaction with operative results, ascribing more symptoms to the esophagus and stomach, when compared to those with supine reflux (P < 0.05). Although all patients reported improvement, the extent of the relief from preoperative symptoms was less in patients with upright reflux (P < 0.05). When asked if, in retrospect, they favored operative therapy, the patients with upright reflux were less enthusiastic (P < 0.05). Although antireflux surgery eliminates reflux in nearly all patients, postoperative symptomatic outcome is related to the preoperative pattern of reflux. Although all patients showed symptomatic improvement, the extent of that improvement was significantly less in patients with upright reflux. These patients should be carefully counseled preoperatively regarding expected symptomatic outcomes.

Adult↗