Biomedical subjects
R M Satava
Publications and source records attributed to R M Satava.
Resident education in surgical endoscopy.
Under the auspices of the Resident Education Committee of the Society of American Gastrointestinal Endoscopic Surgeons, 158 of 298 (53%) of surgical training program directors responded to a survey on the current status of endoscopy in residency programs. Although 100 per cent claim that gastrointestinal endoscopy is provided by their program, only 76 per cent have formal endoscopy training, usually centered around the PGY 3 level, with only 23 per cent having didactic lectures in endoscopy. Directors claim to have trained nearly all of their residents by the completion of residency, averaging 44 esophagogastroscopies, 37 colonoscopies, and 46 flexible sigmoidoscopies per resident. However, they feel only 71 per cent of trainees are able to perform esophagogastroscopies and 67 per cent to perform colonoscopies in clinical practice. Ninety-seven per cent of directors feel endoscopy is important to surgical residency training, and 87 per cent have full-time faculty doing endoscopy. Only 44 per cent have a director of endoscopy; endoscopy is supervised by surgeons exclusively in only 48 per cent. Only 35 per cent have ongoing endoscopy research. When surgeons are not performing endoscopy, 66 per cent feel that the gastrointestinal (GI) service provides adequate service or training. Gastroenterology has a monopoly in endoscopy at 28 per cent of institutions, and 67 per cent of program directors feel there would be resistance to the formation of a separate surgical endoscopy service. Surgeons work in their own surgical endoscopy suite in only 15 per cent of institutions; in a GI suite in 13 per cent; and in a combined suite in the remainder.(ABSTRACT TRUNCATED AT 250 WORDS)
A mass casualty while in garrison during Operation Desert Storm.
In the theater of operations, rear echelon hospitals by doctrine receive patients who have been stabilized by forward hospitals. Occasionally, mass casualties will occur in the rear area, but rarely from combat causes. This report documents a mass casualty occurring in garrison from an anti-tank weapon misfiring. All rear echelon hospitals, regardless of their mission, must be prepared for the acute care of combat mass casualties.
Operating under the threat of chemical-biological warfare.
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Surgical endoscopy during the Gulf War.
During Operation Desert Shield/Desert Storm, the 8th Evacuation Hospital (400 beds) evaluated the efficacy of endoscopy in the desert environment. Standard off-the-shelf fiber-optic endoscopes met the criteria of being rugged, versatile, portable, and easy to maintain. Over a 3-month period, 36 procedures (Esophagogastroduodenoscopy, 25; colonoscopy, 7; flexible sigmoidoscopy, 4) were performed in soldiers both in the garrison and in combat. Of these, 24 (67%) revealed normal findings; the remaining 33% demonstrated pathology (6 cases of peptic ulcers, 3 cases of esophageal ulcers, 2 cases of acute ulcerative colitis, and 1 case of proctitis). Two-thirds of the patients could immediately be returned to duty because they demonstrated either a normal examination or pathology that would resolve with medical management. Another 17% of the subjects were promptly air-evacuated out of the combat theater, and 17% were Iraqi prisoners of war in whom the proper medication was begun. Although no indication for surgical endoscopy was found that was unique to a combat theater, these procedures greatly enhanced the conservation of the fighting force, especially in determining which soldiers could be immediately returned for a combat mission.
Surgical endoscopy training: benefit to army-wide medicine.
To assess the benefit of surgeons being trained in endoscopic procedures, the gastrointestinal endoscopic experience of all surgical residents graduating from a single medical center in the 1984-87 period was evaluated. For the 1989 1-year period, the surgeons' aggregate total of gastrointestinal endoscopic procedures was 1,040: 470 EGDs and 570 colonoscopies. During a 3-year (1987-89) period, the total was 2,290 procedures: 1,080 EGDs and 1,210 colonoscopies. While the cost savings for over 1,000 endoscopic procedures a year is obvious, it is the impact of the accessibility of these procedures on quality patient care that is of the greatest benefit. In this era of financial constraints and personnel cutbacks, the incorporation of gastrointestinal endoscopy into surgical training must be insured and surgeons must be encouraged to pursue their endoscopic skills throughout their surgical careers.
A safe method for sedating and monitoring patients for upper and lower gastrointestinal endoscopy.
Although the incidence of significant complications occurring during endoscopic procedures that require sedation are low, it has been demonstrated that they are usually related to cardiovascular system dysfunction. Such complications are a manifestation of cardiac hypoxia and are a function of the arterial oxygen desaturation. A practical method of monitoring such patients includes continuous oxygen saturation measurements and EKG monitoring. From October, 1987 to July, 1989, a total of 730 endoscopic examinations were performed using a combination of meperidine and midazolam as an intravenous (IV) bolus for sedation. Supplemental nasal oxygen was routinely given at 2 L per minute and real-time monitoring was performed with electrocardiograph and continuous pulse oximeter. There were no deaths and only four untoward events related to medication that altered the course of the examination. Transient hypoxemia that responds to gentle stimulation and bradycardia resolving with cessation of endoscope advancement are viewed as physiologic responses and not complications. All occurrences were immediately identified and corrected appropriately, and no morbidity resulted. With proper monitoring of oxygen saturation, pulse, and cardiac rhythm in a patient with nasal oxygen, IV bolus administration of meperidine and midazolam is a safe and adequate sedation even in the elderly and debilitated patient.
An artificial anal sphincter. Phase 2: Implantable sphincter with a perineal colostomy.
To find an alternative to the stigmata of abdominal colostomy, an artificial anal sphincter (utilizing the currently available artificial urinary sphincter) was implanted around an end perineal colostomy following standard abdominal perineal resection. Of 13 swine, 7 completed full evaluation with working sphincters, 3 animals died prematurely of unrelated causes, and 3 animals were sacrificed due to sphincter slough before inflation was begun. Seven animals had long-term evaluation of the sphincter for 2 to 6 months' duration. In 5 animals (72%) there was complete fecal continence; one animal (14%) had occasional partial incontinence and one had total incontinence, both due to sphincter malfunction from breakage of the connecting tab. Two of the seven animals had delayed slough of the sphincter after 2 months and 4.5 months of success, and 2 animals had erosion of the intraperitoneal balloon reservoir into the small bowel. In addition, 5 of 9 (55%) control pumps were complicated by skin erosion or infection; all were relocated successfully. The fact that an intact artificial anal sphincter can provide excellent continence demonstrates that this concept of perineal placement for bowel control is valid. Refinements in the device to prevent tab breakage, investigation of correct sphincter pressures to prevent sloughing, and better sites for implantation of the pump and balloon reservoir are requisite solutions for a fully implantable system to restore near-normal bowel function after radical abdominal perineal resection.
Establishing an endoscopy unit for surgical training.
Gastrointestinal endoscopy is slowly returning to the core of surgical resident training. The intent is to integrate endoscopy into the mainstream of surgical education such that it will be approached and used the same as any of the many diagnostic and therapeutic tools at the surgeon's disposal. The current feeling is that although endoscopy should be intimately incorporated into training, there is a level of technical expertise required such that a dedicated teaching experience must be provided. This education must be directed by a surgeon experienced in endoscopy; we should not abdicate this responsibility to others. The training program should be founded on education, clinical practice, and research, with technical skills to begin in PGY 2 or PGY 3 and be incorporated throughout the remainder of training. Quality assurance should be monitored closely but not separately from that of the surgical service. Certification of the resident should not depend on numbers, nor be specifically singled out from the body of surgery. There is adequate patient demand to establish the endoscopy unit under the supervision of a surgeon, either as a separate unit or as part of the surgical clinic. However, as the number of endoscopic procedures performed approaches 600 per year, a fully dedicated endoscopy room and full-time gastrointestinal assistant technician are required. The most efficient method of postsedation recovery is through coordination with an ambulatory surgery unit or postoperative recovery room. The current standard for equipment is video endoscopy in order to provide the most efficient method for surgical training.
The impact of video endoscopy on surgical training.
The impact of video endoscopy on surgical resident training was assessed by an analysis of 1531 endoscopic procedures (1057 video endoscopy and 474 fiberoptic endoscopy) and a standardized questionnaire response of surgical staff and residents. Video endoscopy provided advantages in the following areas: 1) Technical. Superior quality of image with a significantly greater resolution. 2) Procedural. Multiple simultaneous viewers for teaching and increased coordination for therapeutic maneuvers. 3) Educational. "Freeze frame" capability for real time teaching; video taping for subsequent consultation, review, or teaching conference, video tape evaluation at preoperative conferences, and archive of video tape for teaching file. 4) Documentation. For use review and quality assurance or for patient education. 5) Research. Investigation of video image enhancement techniques. 6) Physical comfort. Relief of many causes of strain and fatigue and elimination of potential danger to the endoscopist in certain therapeutic maneuvers. Residents learned video and fiberoptic endoscopy equally well, requiring only 3 to 5 procedures to learn each type of system. Experience in this teaching program indicates a decided advantage to incorporating video endoscopy into surgical residency training. After more than 1000 video endoscopy procedures, the novelty has worn off but enthusiasm persists; the video system is now a workhorse that provides greater technical capabilities and broader educational horizons while returning endoscopy to the realm of surgical education.
Splenic autotransplantation: determination of the optimum amount required for maximum survival.
Splenic salvage in cases of traumatic or iatrogenic injuries may require autotransplantation of splenic fragments when splenorrhaphy or partial splenectomy is not possible. There are no studies which address the issue concerning the optimal amount of spleen to be transplanted in order to yield maximal survival in a model of pneumococcal sepsis. This study uses a Sprague-Dawley rat model to attempt to clarify this issue. Animals were divided into seven groups: control, total splenectomy, 25, 40, 60, 80, and 100% omental pouch autotransplantation. These animals were challenged with intravenous Streptococcus pneumonia Type I after 24 weeks, and mortality and blood culture results were monitored. Transplants were recovered and weights were compared with the weights originally transplanted. Survival and blood culture results were seen to improve in a linear quantitative fashion as the amount of spleen autotransplanted increased up to 80%, after which no further improvement was seen. This data supports the autotransplantation of 80% of the spleen in the Sprague-Dawley rat as the optimum amount to achieve maximal survival in a model of pneumococcal sepsis.
Preoperative endoscopy: the impact on planned surgical procedures.
Of 1,504 endoscopic procedures in a two and one half year period, 296 (20%) were performed prior to elective surgery or an invasive diagnostic procedure. From these "pre-op clearance" procedures, there were 66 (22%) positive findings. Due to these endoscopic findings, 29 patients (44% of positive findings or 10% of all pre-operative evaluations) had an alteration of planned treatment. The indications for preoperative endoscopy in these patients were: atypical symptoms of diagnosed gastrointestinal (GI) tract disease, symptoms of GI tract disease unrelated to an elective surgical procedure, history of prior GI tract disease which may complicate elective surgery, and evaluation of a portion of the GI tract prior to operating on that segment. Judicious use of preoperative endoscopy following the above guidelines can decrease adverse surgical outcomes.
Current generation video endoscopes. A critical evaluation.
Video endoscopy is the latest technical advance in the observation of the gastrointestinal tract. In 2 years, three video endoscope systems have emerged to develop the field of digital imaging. In order to accurately assess the rapidly changing technology, these state of the art systems were "bench" tested in an electronics laboratory to objectively compare resolution, brightness (luminosity), color intensity (chroma), and field of view. All systems were excellent, surpassing the professional broadcasting minimum standards for the adequate discrimination of objects and colors. The Welch Allyn Video-Endoscope originated video endoscopy continued to demonstrate a superior resolution; however this was at the expense of a significantly more narrow field of view, relative to the two newer systems. Although all systems have adequate luminosity and chroma, there were differences in the maximum amounts of luminosity and chroma. This is reflected in the observation that the most recently introduced system, Olympus Endoscopic Video Information System had relatively low levels of light beyond 9 cm from the tip, while the other systems had ample illumination. This report on the relative advantages of each system is based on the interpretations, implications, and practical applications of these findings.
Surgery in space. Phase I: Basic surgical principles in a simulated space environment.
The venturing forth of man into space confronts the surgeon with a new weightless environment with which he will inevitably have to contend. In this study operative procedures were performed on 20 rats in a simulated space environment with use of neutral buoyancy in order to identify those factors that could actually or potentially affect operative technique. There are three general areas of difference from normal conditions in simulated microgravity: physical adaptation to gravity deprivation tissue behavior, including bleeding; and the conduct of surgery. Without gravity, the tactile "feel" of objects is changed ("heavy" and "light" are meaningless terms) and proprioception is confused so that there is past pointing and overreaching of movements. Tissue planes tend to separate, and organs float and bob in the operative field, which makes clamping, cutting, and suturing different. Bleeding is a major consideration; surface tension tends to keep venous blood oozing along surfaces, whereas pulsatile arterial blood forms droplets, streamers, and clouds, depending on the force of the bleeding. These factors and others interfere with surgical technique in a number of ways: dispersion of blood obscures the surgeon's vision, sutures become entangled, organs are not stabilized, and instruments float into the operative field. The limitations of comparing neutral buoyancy to the true zero gravity of space are addressed. There is a definite need for further investigation for development of new surgical techniques in preparation for experimental and clinical surgery in space.
A comparison of direct and indirect video endoscopy.
The advent of microchip video cameras has opened another technology to endoscopy of the gastrointestinal tract: video endoscopy. With direct video endoscopy, the microchip camera is mounted on the distal tip of the endoscope; with indirect video endoscopy, a miniature camera is coupled to the eyepiece of a standard fiberoptic endoscope. Both systems view the procedure on a monitor. The systems were "bench" tested in an electronics laboratory to objectively compare resolution, brightness (luminosity), and color intensity (chroma). Clinical comparison was performed in 619 patients. Both video endoscopy systems provided significant advantages over fiberoptic endoscopes in therapeutic procedures, teaching, and documentation. The direct video system provided the best overall video image; the indirect system had a slightly diminished resolution and luminosity in both the "bench" test and clinical evaluation.
Comparison of omental splenic autotransplant to partial splenectomy. Protective effect against septic death.
The possible benefit of either partial splenectomy or splenic autotransplantation as protection against post-splenectomy sepsis was investigated. Sprague-Dawley rats were challenged with intravenous Streptococcus pneumoniae and the incidence of bacteremia and mortality were recorded. Animals were divided into four groups based upon the amount of splenic tissue conserved: total splenectomy (0%), partial splenectomy (62%), splenic autotransplantation (27%), or sham celiotomy (100%). A statistically significant (P 0.05) decrease in the incidence of septic death was seen in comparing the total splenectomized animals (63%) to the autotransplant group (27%), the partial splenectomy (4%) and the control group (4%). This diminishing mortality is inversely proportional to the amount of splenic remnant in the respective groups. There was a similar, parallel relationship in the incidence of Streptococcus pneumoniae bacteremia. Thus, the greater the amount of remaining splenic tissue, the lower the incidence of bacteremia and subsequent mortality, implying the preservation of immunologic function with splenic conservation.
Success rate of cervical exploration for hyperparathyroidism.
In a three-year experience with 361 patients who underwent exploratory surgery for hyperparathyroidism, the success rate for primary cervical operations was 95% and that for secondary operations (cervical and mediastinal) was 62%; for all operations, it was 94%. The three most important factors in determining successful cervical exploration of the parathyroid glands are correct preoperative diagnosis, meticulous surgical technique, and accurate determination of abnormal locations of pathologic conditions. Ancillary studies or techniques for preoperative localization of parathyroid tissue were utilized in only a few patients who had unusually complicated problems. The results of this study suggest that, because of cost, time involvement, and potential risk, selective venous sampling with radioimmunoassay of parathyroid hormone or arteriography or both should be reserved for complicated problems and for patients being considered for a second or third exploratory operation.
Omental arteriovenous fistula following liver biopsy.
A case of iatrogenic omental arteriovenous fistula attributable to an earlier unsuccessful liver biopsy is presented. The complications of liver biopsy and the role of arteriography in the diagnosis and management of visceral arteriovenous fistulas are discussed.