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PubMed1994

Laparoscopic general surgery: current status and future potential.

In the 1990s, a sweeping change has occurred in general surgery driven by patients demanding cosmetically appealing incisions and speedier recuperation. Established surgeons have swarmed to academic and industry-sponsored courses to learn basic laparoscopic techniques. Hospitals have been forced to redesign operating suites and retrain nurses to keep pace with the technological changes. Industry has responded to powerful market forces with new high-tech equipment and a substantial investment for research and development. More and more, surgeons are collaborating with gastroenterologists, sonographers, and interventional radiologists with the hope of advancing minimally invasive surgical techniques. This article highlights the current status of laparoscopic surgery in the United States and foretells exciting advances for the future [1].

Contraindications↗

PubMed1986

[Quality assurance in general surgery by prospective patient documentation. A comparison over 5 years].

All patients who had undergone general surgery in three different periods of time were prospectively recorded. Results were found to have been improving with significance owing to peri-operative antibiotic prophylaxis, mechanical suturing (for gastro-intestinal anastomoses), and introduction of a system of regular documentation. Rates of postoperative complications were also affected by the individual surgeon's efficiency and techniques.

Anti-Bacterial Agents↗

PubMed2001

Integrating educational objectives and the evaluation process in a general surgery residency program.

Although the Accreditation Council for Graduate Medical Education (ACGME) requires that all of its approved residency programs have written goals and objectives and an evaluation process, many programs have difficulty achieving these goals. For eight years, the general surgery residency program at Abington Memorial Hospital has used a system that integrates each rotation's cognitive, clinical, and procedural objectives into the faculty's evaluation of residents and residents' evaluation of the rotation. The integration of goals and objectives with the post-rotation evaluations provides the program with an ongoing and continual assessment of each resident's progress, the effectiveness of the faculty as teachers, and the educational value of each rotation. In this essay, the authors describe this integrated system and provide examples of one rotation's goals and objectives and the evaluation forms used by faculty and residents.

Evaluation Studies as Topic↗

PubMed1998

Endoscopic retrograde cholangiopancreatography in a general surgery training program.

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most complex procedures performed by endoscopists. ERCP has been performed primarily by gastroenterologists. There have been no reports in the literature regarding ERCP training within the framework of a general surgery residency program. The purpose of this study was to review ERCPs performed by surgical attendings and resident staff during a 6-year period and compare the success and complication rates with those found in published gastroenterological series. There were a total of 193 ERCPs performed on 171 patients for a success rate of 82.4 per cent and a complication rate of 6.7 per cent. A resident was the primary endoscopist in 51 procedures, with 42 (82.4%) successes and 2 complications (3.9%). There were no significant differences noted between our series and national complication rates, and between attending and resident procedures (P < 0.05, Chi-square analysis). This study has shown that surgical endoscopists can perform ERCP with success rates over 80 per cent, the currently regarded standard of expertise. The complication rates for these ERCPs were lower than accepted complication rates cited in current gastroenterological series. The results of this study support the hypothesis that ERCPs can be performed safely in a surgical residency.

Cholangiopancreatography, Endoscopic Retrograde↗

PubMedDate not supplied

Residency reform: anticipated effects of ACGME guidelines on general surgery and internal medicine residency programs.

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) has recently amended guidelines for resident work environment. This study was conducted to evaluate opinions of program directors regarding the impact of the changes on residents and residency programs. METHODS: General surgery and internal medicine program directors were sent a 19-question survey. Questions were asked regarding anticipated effects on patient safety, resident well-being, education, medical errors, implementation costs, and methods needed for compliance. Data were analyzed using the chi-square test, the Mann-Whitney method, and the independent samples t-test where appropriate. RESULTS: Responses were received from 153 surgery program directors and 126 medicine program directors. Differences noted were hours worked (surgery 84.2 hours vs medicine 68.7 hours, p < 0.0005), current compliance (49% vs 73%, p < 0.0005), and allowance of internal (13% vs 54%, p < 0.0005) and external (24% vs 58%, p < 0.0005) moonlighting. CONCLUSIONS: Program directors anticipate improved resident safety and well-being. However, education, continuity of care, and board certification success are not expected to improve. Increased cost to institutions is anticipated. Surgery program directors feel medical errors will not decrease; medicine program directors are neutral. To facilitate compliance, surgery program directors anticipate employing physicians' assistants and technology, whereas medicine program directors may implement night float. Neither surgery nor medicine program directors expects increased quantity or quality of applicants. Program directors agree resident work hour reform is essential; however, varied methodology and outcomes are expected.

Faculty, Medical↗

PubMed1995

Operative experience of U.S. general surgery residents in thyroid and parathyroid disease.

BACKGROUND: We wanted to determine whether the experience of general surgery residents is adequate and effective. METHODS: The Resident Statistic Summaries (Report C) of the Residency Review Committee (Surgery) for 8 academic years from 1986 through 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed. RESULTS: For thyroidectomy the average per resident ranged from 10.3 to 12.6. The maximum ranged from 52 to 102. The standard deviations ranged from 6.96 to 8. The most common number of thyroidectomies performed ranged from 7 to 10 per graduating resident. For parathyroidectomy the average ranged from 4.1 to 5.1, the standard deviations were 3.44 to 4, the maximum ranged from 25 to 60, and the most common number performed was 2. CONCLUSIONS: U.S. graduates have highly variable experience in thyroid and parathyroid surgery. Most residents have inadequate experience in parathyroid surgery and marginal experience in thyroid surgery.

Humans↗

PubMed2002

Relationship between hospital infection and long-term mortality in general surgery: a prospective follow-up study.

A prospective study of 1431 patients admitted to a general surgery department were followed up for a median of 6.2 years after discharge (7679 person-years of follow-up). We collected information on underlying conditions, including severity of illness, and healthcare-related variables. Relative rates of death and their 95% confidence interval (CI) were estimated using person-years as the denominator. Multiple-risk factors adjusted for relative rates (RR) were obtained using Poisson regression analysis. There were 172 deaths during the follow-up period after hospital discharge (2/100 person-years). Follow-up was complete in 91% of the cohort. There were no important differences in demographic characteristics or risk factors between patients followed up and those lost to follow-up. The death rate in patients with any hospital-acquired infection was 5.3/100 person-years, and the relative rate was 3.07 (95% CI: 2.20-4.24). After adjusting for the main predictors of mortality, we found an effect modification by the presence of chronic disease (P = 0.01 for the product-term between hospital infection and the diagnosis of chronic diseases). Among patients without any underlying chronic disease, hospital-acquired infection was related to a significantly higher long-term mortality (RR = 2.47, 95% CI: 1.24-4.91). In these patients, surgical wound infection yielded a RR of mortality of 3.44 (95% CI: 1.63-7.27). Among patients with underlying chronic disease no association between hospital infection and long-term mortality was found. No evidence of an important modification of the relative rate along the follow-up period was observed. In conclusion surgical patients without chronic disease developing hospital-acquired infection have an increased risk of long-term mortality.

Adolescent↗

PubMed1992

A technical-skills course for 1st-year residents in general surgery: a descriptive study.

The proper teaching of operative skills to surgical residents is increasingly constrained by operative time, complex procedures and medicolegal concerns. A technical-skills program was developed and introduced over a 3-year period to 28 1st-year residents in general surgery. To introduce the residents to the principles of surgical techniques in a simulated environment outside the operating room, the program consisted of a combination of two didactic sessions and six "wet labs" taking 3 to 4 hours per week for 8 weeks between January and March each year. The didactic sessions included instruction on suture material and the use of stapling devices; the "wet lab" used a "hands-on" approach. Educational objectives in the "wet lab" included instruction on preparation of the patient and draping, aseptic technique, principles of bowel anastomosis, incisions, instrument use and handling, principles of hemostasis, intraoperative surgical emergencies, surgical assisting and overall conduct in the operating room. The residents' surgical technique and skills improved over the course period. The overall value, teaching and understanding of surgical principles were rated highly. Problems cited during resident feedback were the use of live animals and insufficient time to practise. The efficacy of a surgical-skills program has been demonstrated, but its effectiveness requires further evaluation.

Canada↗

PubMedDate not supplied

Surgical caseload in army general surgery programs: a 10-year retrospective.

PURPOSE: Over the past decade, the Army Medical Department (AMEDD) has been affected by a military-wide drawdown. The volume and acuity of patients appears to be declining, raising questions regarding quantity and quality in Army surgical training programs. The purpose of this study is to examine the caseloads of Army general surgery programs compared with national averages, and to compare the board examination performance of Army residents with national pass rates. METHODS: The program directors of all 6 Army training programs were requested to submit resident caseloads and performance on qualifying and certifying examinations from 1990 to 2000. The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Surgery (ABS) provided resident statistics summaries and board examination statistics, respectively, for the same period. Total caseloads, chief resident cases, performance in defined categories, and board pass rates of military residents were compared with national averages. RESULTS: Four of the 6 programs submitted the requested data. The average caseload for Army residents, both total and chief residents, has been lower than the national average over the past decade. Nationally, total case numbers have gradually increased while military changes have been variable. The number of chief resident cases has trended steadily downward in Army programs at a rate exceeding the national average. The volume of procedures in endoscopy, thoracic, and breast surgery in the Army generally exceeds those recorded outside of the military. Despite the decline in surgical cases in the military, the pass rates in both the certifying and qualifying examinations among Army graduates have been consistently higher than the national average. CONCLUSIONS: Residents who train in Army programs perform fewer operative cases than do their counterparts in civilian programs. The downward trend in the number of chief resident cases over the last 10 years is likely reflective of the changes in military medicine. Despite these trends, Army residency graduates continue to exceed national performance averages on the ABS qualifying and certifying examinations.

Journal Article↗

PubMed1995

How many trainees are needed in general surgery? A computer model to facilitate planning.

As a consequence of the reduction in junior doctors' hours, the intention to shorten training and the freedom of Trusts to appoint additional consultants, the requirement for trained surgeons has increased sharply. Whether this consultant expansion will be sustained, so as to reach the target of one general surgeon to 30,000 population, is uncertain. To improve the planning of the number of trainees in this unstable environment, a computer model has been established for the numbers of higher surgical trainees (HSTs) and consultants. Using a series of scenarios the model demonstrates that the existing number of HST posts, with a six-year duration of training, cannot deliver the intended 1767 consultant posts until about 2016. The target can be reached in 2009 by shortening HST to five years or by the conversion of visiting registrar posts to career HST; both measures combined can achieve the target by 2006. Thus urgent action is needed to increase the output of HSTs in general surgery. In view of the uncertain demand for additional consultants, the number of trainees, in each year of HST, should be monitored frequently. The number entering training may then be adjusted appropriately.

Computer Simulation↗

PubMed2003

Current status and future directions of geriatric general surgery.

As the population ages and requires more health care, a significant part of this is in surgical services. As elderly patients account for a growing proportion of most surgeons' practices, it is apparent that this patient group has special requirements, differences in outcomes, and different physiology from other patients encountered in the typical surgical practice. The greater frequency of emergency operations in older than in younger patients, with higher morbidity and mortality rates, compounds these differences. This paper reviews the current status of general surgery in older patients with a special focus on emergency procedures, major abdominal surgery, biliary disease, endocrine disease, and breast cancer. Each of these areas is a source of considerable interest to general surgeons.

Aged↗

PubMed1991

Unexpected, difficult laryngoscopy: a prospective survey in routine general surgery.

A prospective study of unexpected, difficult laryngoscopy was carried out. During a 7-month period, all general surgery patients in whom the trachea was intubated were assessed; only those with obvious neck pathology were excluded. Ease or difficulty of laryngoscopy was graded by a standard method. There were no grade 4 cases and no failed intubations in a total of 1387 cases. There were significant differences in the results recorded by different individuals; this did not correlate with seniority or with the type of surgery. Four factors have been identified which help to explain these discrepancies. These findings are analysed in relation to the training of junior staff, with particular reference to obstetric anaesthesia.

Anesthesia, Obstetrical↗

PubMed1991

[Respiratory risk of general surgery in adults].

Disorders of ventilation and postoperative bronchial and pulmonary infections still create serious problems in general surgery. Three factors determine these complications: (1) the transient and usually resolutive repercussions of anaesthesia on ventilation; (2) the sometimes deep and prolonged alteration of lung function directly due to the surgical procedure, and (3) the patient's underlying condition. In practice, this last group of surgical patients can be divided into fragile subjects (elderly people, pregnant women), subjects at risk (smokers, malnourished or obese patients) and disabled subjects suffering from chronic obstructive or restrictive lung disease, asthma or heart disease. Preoperative clinical, radiological and, chiefly, functional evaluation leads to preventive measures. Preparation for surgery relies, to a great extent, on respiratory physiotherapy which, if needed, may be integrated in a pneumological therapeutic program. Combined with an efficient postoperative analgesia and with an optional anaesthesia technique, respiratory physiotherapy is essential to the prevention of respiratory complications in surgery.

Adult↗

PubMed1990

Observations with Norcuron in general surgery cases.

Norcuron, a neuromuscular blocking agent of medium duration of action has been applied to 50 general surgery patients. The muscle relaxant assured the muscle relaxation required for performing operations of 25'-180' duration, if required by repeating the drug administration. The drug had no cardiovascular side-effects. It's action could be easily and rapidly antagonized. In spite of the relative overdosage used by the author unexpected phenomenon did not occur and the unwanted effects of Norcuron did not develop. The product is a myorelaxant which may be safely and flexibly used and the doses of which may be easily changed.

Adult↗

PubMed1990

[Intensification of surgical activities in the department of general surgery].

The authors intensified and improved considerably the qualitative indices of surgical activity in a department of general surgery by means of simple and practicable organizational measures and by changing the tactics of surgical management of some diseases. This allowed the conclusion that the number of beds in the department must be reduced by 15 without reduction of the staff, which will not affect the activity of the department unfavourably. The organization of a resuscitation department without additional expenses is planned at the cost of the measures mentioned above.

Bed Occupancy↗

PubMed1989

[Pharmacologic prevention of deep postoperative venous thrombosis in general surgery].

The most commonly used pharmacological aids employed in the prevention of peroperative deep venous thrombosis in general surgery are reviewed in brief. The probable action mechanisms, recommended doses, laboratory parameters to be monitored, side-effects, contraindications and effectiveness shown in the main clinical trials carried out are illustrated.

Fibrinolytic Agents↗

PubMedDate not supplied

[Preventive treatment of thrombo-embolism in general surgery. A report of 5 242 observations (author's transl)].

5 242 patients in a ward of general surgery have been submitted to prevention by subcutaneous injection of calcium heparinate. In all coagulolytic balance has been measured by thromboelastogram on whole blood. The aim was to reduce any hypercoagulability and maintain orthocoagulability. Three fourths of the patients had preoperative hypercoagulability, which may be responsible of precocious migrations. Except emergency, this hypercoagulability was first treated. The heparin dosis was scheduled according to age, weight and degree of hypercoagulability, and the treatment maintained at least 15 days. These are the results: thromboembolism 2,48 % (lethal 0,76 %). All registered accidents were the consequence of gross error. Heparinotherapy has been stopped in only 3 patients; there was no special hemorrhage during operation.

Blood Coagulation↗

PubMed2003

Attributes of trainers for postgraduate training in general surgery--a national consensus.

BACKGROUND: The aim of this study was to obtain consensus amongst consultant surgeons on the attributes of a good surgical trainer that can be used to inform continuing professional development programmes for trainers. METHODS: good trainer attributes were generated from an intensive qualitative study using a participative inquiry process with consultant general surgeons and specialist registrars in the Tayside region. These good trainer attributes were then used as the basis of a modified Delphi study; the early rounds of the Delphi simultaneously sought participants' views concerning stated attributes and sought to generate new attributes. A final Delphi questionnaire was sent to all 180 consultant general surgeons in Scotland to identify consensus. RESULTS: The first two rounds of the Delphi process produced 45 attributes covering seven themes: interest in training, trainer as a team member, communication, receptiveness to trainee needs, trainer as a role model, reflection on practice and clinical and operative competence. The final survey identified significant consensus among surgeons. Clinical and operative competence achieved the highest consensus with 89.2% of surgeons believing it to be an essential attribute. CONCLUSIONS: The results indicate that there is consensus on the seven themes identified as essential for a trainer in general surgery. The recognition of the importance by trainers of non-surgical trainer attributes in the changed training structure is encouraging. Surgeons' level of awareness of their roles as a trainer will help inform the level and direction of trainer training and support required as part of a flexible and continuing developmental process.

Education, Medical, Graduate↗