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PubMed2000

[Hospital infections in general surgery wards].

In 1997 the hospital infections programme was accepted by the National Association for Infectious Diseases (Polskie Towarzystwo Zakazeń Szpitalnych--PTZSz). About 100 hospitals from Poland participated in the surveillence system introducing nosocomial infection registration cards in their units. The results of the research were sent to the PTZSz. The results from general surgery departments in 1998 were analysed. This year 79 general surgery units took part in nosocomial infection programme of PTZSz, sending from 1 to 2259 questionnaires. The analysis included 48,964 nosocomial infection registration cards. Nosocomial infection developed in 1,031 cases in the general surgery departments what accounted for 2.11% of all treated patient in that period. Surgical site infections were the most often place of nosocomial infections (37.1%), next skin and soft tissue infections (20.1%), and finally respiratory tract infections (17.6%). The average duration of hospitalization in general surgery departments was 10.2 days. In case of nosocomial infection occurrence the time of treatment was extended three times. The most frequent aetiological pathogenes of nosocomial infections were as follows: Escherichia coli and Staphylococcus aureus.

Adolescent↗

PubMed2005

[Postoperative venous thrombosis in general surgery patients and perioperative prophylaxis].

In a population of general surgery patients in Western countries, there was a 19% incidence of deep vein thrombosis (DVT) and a 1.6% incidence of pulmonary embolism (PE), with 0.9% of patients experiencing fatal PE. In Japan, there was a 15.8% incidence of DVT and a 0.34% incidence of PE, with 0.08% of patients experiencing fatal PE in a population of abdominal surgery patients. The incidences of PE and fatal PE in our department were 0.11% and 0.03%, respectively. We started to use intermittent pneumatic compression (IPC) for the prophylaxis of postoperative PE in 1999 and then added elastic stockings in 2002 and low-dose unfractionated heparin (LDUH) in 2003 for prophylaxis. The incidence of PE has dropped and that of fatal PE has become 0% with the use of such prophylactic measures. When the risk of venous thromboembolism of the 15 patients who experienced PE in our department were assessed using the Japanese Guidelines for Prevention of Venous Thromboembolism, 13 patients were assessed as high risk and 2 as low risk. The mean age and mean body mass index of the 15 patients were 54 yeas old and 24.8, respectively, and PE was not limited to obese or elderly patients. Such findings appear to indicate the difficulty of risk assessment for PE. Therefore we started to use IPC, elastic stockings, and LDUH for the prophylaxis of PE and DVT for all general surgery patients from April 2004. These prophylactic measures are recommended for the highest-risk patients in the Japanese Guidelines for Prevention of Venous Thromboembolism. There have so far been no serious bleeding complications with the administration of LDUH. We will continue to observe the effects of prophylaxis and the risk of bleeding.

Female↗

PubMed1997

Leaving the nest: should vascular surgery seek board status separate from general surgery?

Current changes that impact on vascular surgery include altered financial support, the introduction of endovascular treatments, and possible reentrance of general surgeons into the vascular field. In addition, vascular surgery in competition with interventional specialties (radiology and cardiology) for patients. These changes and the enhanced competition mandate that vascular surgery and vascular surgeons adapt by becoming competent with endovascular techniques to perform their standard operations better and to provide newer, better treatments that replace standard vascular operations. Vascular surgery must also resolve its conflicts with the American Board of Surgery (ABS) and the Residency Review Committee in Surgery (RRC-S) so that adequate numbers of well-trained vascular surgeons will be available to care for vascular disease patients optimally. Whether this can occur by modifying the present system or by having a separate board and residency review committee in vascular surgery will depend on the willingness of the ABS and the RRC-S to recognize that vascular surgery is a separate specialty that is best performed by those with special training and commitment to this field.

Certification↗

PubMed2006

General surgery in crisis--the critical shortage.

INTRODUCTION: General surgery is facing a serious crisis. There has been a significant decline in the number of applicants for registrar posts and an inability to attract and retain general surgical specialists in the state sector. The Association of Surgeons of South Africa (ASSA) undertook this study to determine the extent and cause of the problem. METHODS: The study involved a combination of desk research and structured interviews. In addition, the Health Professions Council of South Africa (HPCSA) database was reviewed and compared with the South African Medical Association (SAMA) and ASSA databases. The medical schools provided information about student numbers and demographics, and the National Department of Health pro vided information about the status of medical practitioner and specialist posts in the state sector. RESULTS: Overall, 26.1% of the specialist posts were vacant. The situation was particularly critical in Mpumalanga and the Eastern Cape, where 84% and 58% of the specialist posts were vacant. Using a predictive model, a conservative estimate of the need for general surgeons was found to be at least 50 per year. Currently the eight medical schools graduate about 25 general surgeons per year. The changing demographics of medical students may be partly responsible for the decline in registrar applicants. CONCLUSION: The findings from this study have revealed that the shortage of general surgeons in the state sector has reached critical levels.

Career Choice↗

PubMedDate not supplied

Preliminary general surgery residents: indentured servitude or golden opportunity?

BACKGROUND: One-year, preliminary general surgery (GS) positions are viewed by medical student applicants as among the least desirable positions offered through the match. Hundreds of preliminary GS positions go unfilled each year, and international medical graduates (IMGs) fill a substantial portion of the spots filled. "Prelims" foster diversity and add manpower to surgical training programs, but do trainees eventually benefit from this 1-year effort? METHODS: Nondesignated (ND) preliminary GS residents at the Mayo Clinic, Rochester, Minnesota, were identified from 1993 to 2003. Trainees were followed (telephone, e-mail, Internet registries) looking at subsequent training, specialty choice, and eventual practice location. RESULTS: From 118 ND preliminary GS residents, the current data of 105 (46 U.S. medical graduates, 59 IMGs) trainees are known. Thirteen trainees (11%) progressed on to a second year of training (location: United States=10, international=3), but they could not be located thereafter. Two additional prelims chose another profession. Seventy one of the remaining 103 prelims (70%) advanced to other non-Mayo residency programs to continue or finish their training in general surgery (n=22), a surgical subspecialty (n=26), or some other field (n=23). Thirty-two prelims remained at Mayo Clinic-Rochester in GS (n=16), a surgical subspecialty (n=12), or a nonsurgical field (n=4). From the 59 IMGs, 52 remained in the United States, whereas 7 left for another country to practice medicine. CONCLUSION: Most of our ND preliminary GS residents progress toward completion of surgical or medicine residencies. Although initially described as a finite period of training, the 1-year preliminary GS residency offers both U.S. and international students opportunity for career advancement.

Adult↗

PubMed2003

[Nutrition support of severe illness patients of general surgery during peroperation period].

OBJECTIVE: To study the clinical effect of the nutrition support of severe illness patients of general surgery during peroperation period. METHODS: To analyse application of the nutrition support applied to 147 cases with severe illness of general surgery in peroperation period since 1995. In 147 cases, there were abdominal operations(n=138, 93.9%) and cervical operations(n=9, 6.1%) and emergency operations (n=63, 42.8%). Total parenteral nutrition (TPN) was used by venous canal ways including internal jugular vein (n=132, 89.8%), axillary vein (n=11, 7.5%), femoral vein (n=4, 2.7%), used unicameral catheter (n=127, 86.4%), double catheter (n=20, 13.6%), 41 cases were used enteral nutrition. Two different nutritional support treatments were employed, one was TPN-->parenteral nutrition(PN)+oral diet-->oral diet (n=106, 72.1%) and another was TPN-->PN+enteral nutrition(EN)-->EN-->EN+oral diet-->oral diet (n=41, 27.9%). RESULTS: There were not complications of catheterization and metabolism in the nutrition support, 142 cases (96.6%) had been cured and 5 cases (3.4%) died of primary diseases after operation. CONCLUSION: The nutrition support of patients with severe illness of general surgery in peroperation period is an important adjuvant treatment that can assure operative safety and promote recovery on postoperation.

Adolescent↗

PubMed2004

Minimal-access surgery training in the Netherlands: a survey among residents-in-training for general surgery.

BACKGROUND: The purpose of this study was to assess the state of surgical training and its possible shortcomings in minimal-access surgery (MAS) among Dutch surgical residents. METHODS: A pretested questionnaire was distributed to all residents-in-training for general surgery in The Netherlands. RESULTS: The questionnaire was sent to 407 surgical residents. The response rate was 65%. Overall, 87.7% of all the responders were highly interested in the autonomous performance of laparoscopic surgery. Residents interested in gastrointestinal (GI) or oncologic surgery (n = 137) are significantly more interested than residents interested in non-GI/oncologic surgery. All the residents (100%) thought it was important to be able to perform the three basic MAS procedures (diagnostic laparoscopy, laparoscopic cholecystectomy, and laparoscopic appendectomy) autonomously at the end of their surgical training. Other MAS procedures were considered to be advanced procedures. Gastrointestinal/oncologic residents were most interested in performing advanced MAS procedures, although only 17.8% expected to be adequately prepared at the end of their surgical training. Most residents had the opportunity to attend MAS skills education. Irrespective of the format or training method, only 26.9% of residents stated their MAS skills training was objectively evaluated. The residents thought every surgical hospital department in the Netherlands should have a surgeon specialized in laparoscopic surgery (86.9%). CONCLUSIONS: The current study showed that Dutch residents believe it is very important to perform basic MAS autonomously. Of the GI/oncologic-interested residents, the majority want to be able to perform advanced MAS, but expect to be unable to do so at the end of their training. They attribute this discrepancy to "not having enough chance to be the first operator" and to "lack of volume of procedures in the hospital." Specific and properly implemented, monitored, and evaluated MAS skills training programs in skills laboratory settings could offer a promising environment for overcoming this discrepancy.

Adult↗

PubMed1989

[A sufentanil dosage study in general surgery].

Sufentanil is widely used for cardiac surgery in initial doses up to 15 micrograms/kg. It was expected that for general surgery much smaller doses would be appropriate. The aim of the study, therefore, was to find a dosage scheme for sufentanil that could be used in general surgery for operations lasting 1 h. METHODS. In 62 patients (Table 1), anesthesia was induced with 15 micrograms sufentanil and 0.2 mg/kg etomidate. According to a random group allocation, a bolus injection of sufentanil was administered 1 min before incision, so that the patients received 0.5, 1.0 or 1.5 micrograms/kg along with the initial dose. During maintenance anesthesia, repeat doses of 10 micrograms sufentanil were injected as required (rise in blood pressure and/or heart rate by more than 20%, or other stress signs i.e., sweating, movement). Intubation was facilitated by means of atracurium 0.5 mg/kg. Increments of 5-10 mg were given when needed. RESULTS. In the group of patients who had received 1.0 micrograms/kg, both the number requiring repeat doses, and the total number of repeat doses were significantly lower than in the 0.5 microgram/kg group. A further increase to 1.5 micrograms/kg did not prove to have any advantage and it led to a drop in blood pressure, that was more pronounced and of longer duration than in the other groups. CONCLUSION. A dose of 1.0 micrograms/kg, therefore, appeared to be the optimum initial dose in general surgery for operations lasting at least 1 h.

Abdomen↗

PubMed1996

[Perioperative mortality in elderly patients undergoing general surgery].

OBJECTIVE: To determine wether the physical status (ASA category) and surgical conditions could predict mortality in elderly general surgery patients. PATIENTS AND METHODS: This was a prospective study of patients greater than or equal 85 years of age who underwent elective or emergency surgery under general anesthesia between January 1987 and December 1991. Hospital mortality was defined as death occurring before discharge. Logical regression analysis (Cox's modeling) was used to assess group survival. RESULTS: One hundred and nine patients undergoing 117 operations were enrolled. Major surgery was performed in 70%; 44% were removals of malignant tumors and 84% were under general anesthesia. Hospital deaths occurred in 10%; the only significant predictors were neoplastic disease and emergency status. Mortality was 43% one year after surgery; significant predictors of death were prior physical status, neoplasia and emergency status. CONCLUSIONS: Neoplastic disease, emergency status and poor physical condition are factors that predict mortality in patients 85 or older who undergo general surgery.

Aged↗

PubMed1980

[Antibiotic prophylaxis in general surgery].

In their discussion of the problem of antibiotic prophylaxis in general surgery the authors maintain that routine-like antibiotic prophylaxis is not indicated in general surgery, but is superfluous and even harmful. So-called "b ind prophylaxis" is senseless and there is no "total prophylaxis". Antibiotic prophylaxis can be successful when it is selective, aimed, adapted to the individual subject and the antibiotic reaches an effective concentration at the appropriate moment not only in the serum but also in the tissues. Infection can be of exogenous and of endogenous origin. Prevention of exogenous infections does not depend upon antibiotic treatment. Antibiotic prophylaxis is contra-indicated when the operation is performed o a clean region. The problem of antibiotic prophylaxis in the course of operations of the bile duct, the stomach, the intestine and pancreas. during appendectomy and colorectal operations is discussed in detail. Post-operative infections of the respiratory tract cannot be prevented by antibiotic prophylaxis. Finally, the authors try to find an answer to the problem when and how antibiotic prophylaxis should be applied, what antibiotic should be used for how long and in what doses.

Anti-Bacterial Agents↗

PubMed1978

The high-risk cardiac patient undergoing general surgery.

The challenge of the high-risk cardiac patient undergoing general surgery will be met only when an aggressive approach is taken to avoid an unfavourable balance between the oxygen supply and demand of the myocardium. In the past this challenge has been accepted in the operating room but postoperative care has been less than adequate. The intelligent use of potent, effective pharmacologic agents and intensive monitoring of myocardial performance intra- and postoperatively have greatly reduced morbidity and mortality in patients with ischemic heart disease undergoing aortocoronary bypass procedures; they can achieve similar results in such patients who must undergo general surgery.

Anesthesia, General↗

PubMed2004

Women in academic general surgery.

PURPOSE: To portray the professional experiences of men and women in academic general surgery with specific attention to factors associated with differing academic productivity and with leaving academia. METHOD: A 131-question survey was mailed to all female (1,076) and a random 2:1 sample of male (2,152) members of the American College of Surgeons in three mailings between September 1998 and March 1999. Detailed questions regarding academic rank, career aspirations, publication rate, grant funding, workload, harassment, income, marriage and parenthood were asked. A five-point Likert scale measured influences on career satisfaction. Responses from strictly academic and tenure-track surgeons were analyzed and interpreted by gender, age, and rank. RESULTS: Overall, 317 surgeons in academic practice (168 men, 149 women) responded, of which 150 were in tenure-track positions (86 men, 64 women). Men and women differed in academic rank, tenure status, career aspirations, and income. Women surgeons had published a median of ten articles compared with 25 articles for men (p <.001). Marriage or parenthood did not influence numbers of publications for women. Overall career satisfaction was high, but women reported feeling career advancement opportunities were not equally available to them as to their male colleagues and feeling isolation from surgical peers. Ten percent to 20% of surgeons considered leaving academia, with women assistant professors (29%) contemplating this most commonly. CONCLUSION: Addressing the differences between men and women academic general surgeons is critical in fostering career development and in recruiting competitive candidates of both sexes to general surgery.

Adult↗

PubMed2000

Supervised training of general surgery residents in carotid endarterectomy performed on awake patients under regional block is safe and desirable.

Previous studies have documented the safety and efficacy of general surgery residents and vascular fellows performing carotid endarterectomy (CEA) under the supervision of an attending surgeon. With the proper supervision of the attending surgeon, these operations can be performed with an acceptably low perioperative stroke and mortality rate. The question remains, however, whether these desirable results can be obtained by general surgery residents when operating on awake patients under regional block (RB) anesthesia. We set out to determine whether it is prudent to promote this technique in this teaching setting. We analyzed 128 CEAs performed at a community teaching hospital training three chief residents a year. These operations were performed by residents under the direct supervision of a single attending vascular surgeon. RB was preferred and was used in 67 operations. General anesthesia (GA) was used in the remaining 61 procedures. Overall mortality was 0 per cent. Patients in the RB group were converted intraoperatively to GA in 4 of 67 (6%) procedures. There was one perioperative stroke in this series (1/128, 0.78%), occurring in a patient under RB (1/67, 1.5 %) leaving the patient with a minor sensory deficit. No strokes occurred in the GA group. There were five temporary cranial nerve deficits (3.9%). Three were in the RB group (4.5%) and two in the GA group (3.3%). General surgery residents can be trained in the performance of carotid endarterectomy using regional block anesthesia in awake patients without compromising patient safety. Suggestions to the effect that only attending physicians and/or vascular fellows can perform these procedures under regional block are without merit.

Aged↗

PubMed2000

Plasma tissue factor pathway inhibitor levels as a marker for postoperative bleeding after enoxaparin use in deep vein thrombosis prophylaxis in orthopedics and general surgery.

Low-molecular-weight heparins (LMWH) are widely used as antithrombotic prophylactic pharmaceutical agents in orthopedic and general surgery. Their antithrombotic characteristics are expressed by plasma mediators such as anti-Xa, anti-IIa, and increased release of tissue factor pathway inhibitor (TFPI) from vascular endothelium. The purpose of this clinical research is to study the relation between plasma levels of these mediators and postoperative bleeding. Forty-one consecutive patients undergoing hip or knee arthroplasty (n = 36) and colectomy (n = 5) received the standard enoxaparin (a LMWH) dose preoperatively (general surgery) or immediately postoperatively (orthopedic surgery). Major bleeding was defined as a postoperative drop of > or = 5 g/dL) of hemoglobin. The authors observed that there was a linear relationship between an increase in free/total TFPI ratio levels and postoperative bleeding. When that ratio increased by > 60%, the hemoglobin dropped to > 5 g/dL (n = 17). This relationship between free/total TFPI ratio increase and postoperative bleeding was statistically significant (P < 0.001). Those who did not bleed (hemoglobin drop was less than 5 g/dL) (n = 24) had a ratio increase (if any) of less than 50%. However, the authors did not observe any statistical relationship between anti-Xa, anti-IIa, or prothrombin time and postoperative bleeding in patients receiving LMWH for deep vein thrombosis prophylaxis in orthopedic and general surgery patients. The authors recommend a pre- and postoperative ratio level measurement whenever major bleeding is anticipated, as adjustments of LMWH dose or frequency might be necessary.

Biomarkers↗

PubMed2001

Plasma tissue factor pathway inhibitor levels as a marker for postoperative bleeding after enoxaparin use in deep vein thrombosis prophylaxis in orthopedics and general surgery.

Low-molecular-weight heparins (LMWH) are widely used as antithrombotic prophylactic pharmaceutical agents in orthopedic and general surgery. Their antithrombotic characteristics are expressed by plasma mediators such as anti-Xa. anti-IIa, and increased release of tissue factor pathway inhibitor (TFPI) from vascular endothelium. The purpose of this clinical research is to study the relation between plasma levels of these mediators and postoperative bleeding. Forty-one consecutive patients undergoing hip or knee arthroplasty (n = 36) and colectomy (n = 5) received the standard enoxaparin (a LMWH) dose preoperatively (general surgery) or immediately postoperatively (orthopedic surgery). Major bleeding was defined as a postoperative drop of > or = 5 g/dL) of hemoglobin. The authors observed that there was a linear relationship between an increase in free/total TFPI ratio levels and postoperative bleeding. When that ratio increased by >60%, the hemoglobin dropped to >5 g/dL (n = 13). This relationship between free/total TFPI ratio increase and postoperative bleeding was statistically significant (P < 0.001). Those who did not bleed (hemoglobin drop was less than 5 g/dL) (n = 28) had a ratio increase (if any) of less than 50%. However, the authors did not observe any statistical relationship between anti-Xa, anti-IIa, or prothrombin time and postoperative bleeding in patients receiving LMWH for deep vein thrombosis prophylaxis in orthopedic and general surgery patients. The authors recommend a pre- and postoperative ratio level measurement whenever major bleeding is anticipated, as adjustments of LMWH dose or frequency might be necessary.

Anticoagulants↗

PubMedDate not supplied

[Mechanical suture in classic and laparoscopic general surgery].

AIM: Of this working is the study of employment the mechanical suture in general surgery classic and laparoscopic. MATERIAL AND METHOD: We analysed the possibility of accomplishment and postoperatory evolution of 104 mechanical sutures performed in 24 patients, with diverse surgery pathology, operated in Department of General Surgery, between January 1999 and January 2000. RESULTS: Mechanical sutures allowed us to minimize the duration of surgical interventions and to perform some difficult anastomotic assembles (sometimes including creation of organ substitute). We had only two postoperatory fistulas and two postoperatory haemorrhages from anastomotic area (both cases because of bad closing of clips, through tissue excess between anvil and cartridge of the stapler). CONCLUSIONS: There are certain advantages in using mechanical sutures (versus manual sutures) consisting in decreasing of time period, both in operation itself and in hospitalization, despite their high level cost.

Diverticulosis, Colonic↗

PubMed1997

[Plastic surgery concepts for coverage of extremity defects within the scope of general surgery].

Soft tissue defects of the extremities are infrequent within the spectrum of general surgery and are predominantly found with perfusion disorders of macro- and microcirculation in the lower extremities. In the upper extremity, they are more frequently seen after i.v. cytostatic drug administration and tumor resections. This article describes the most frequent causes of complex defects of the extremities. Common flaps for the reconstruction of these defects and the pathway to decision making are elucidated.

Antineoplastic Agents↗

PubMed1996

A new concept for implementation of a required general surgery clerkship.

BACKGROUND: Two years ago our institution abbreviated the junior internal medicine and general surgery clerkships to accommodate a 4-week family practice clerkship and a 4-week elective clerkship. As a consequence, 1-month mandatory internal medicine and general surgery clerkships were placed in the senior year. METHODS: The surgical disorders most commonly encountered by the generalist are discussed. The senior students spend 4 weeks with a community-based surgeon. All lectures are presented by full-time faculty and adhere to the student manual, which is designed to coincide with examination material. Three histories and physicals are reviewed by the course director to determine utilization of critical thinking skills. The development of healthy interpersonal and professional relationships is addressed by a 2-hour module on the essentials of integrity, compassion, humility, and self-knowledge. A faculty development seminar provides an awareness of course objectives and logistics. Student grades are determined by the preceptor's evaluation (50%), an in-house written examination (50%), and submission of adequate history and physicals. RESULTS: Subjective reviews by students (n = 115) reveal that although only 27% of the students care to pursue a surgical practice, 85% feel that their time was effectively spent and 83% feel that the clerkship should be offered to future fourth year medical students. Seventy percent of submitted history and physicals (n = 420) exhibit appropriate critical thinking skills. CONCLUSIONS: We are currently in the midst of our third year of implementation. The students are receiving insight into a surgical approach to common disease processes. History and physical examination skills and healthy interpersonal relationships are reinforced. Although change is often difficult to accomplish and accept, the positive response to the newly formatted senior curriculum has exceeded expectations.

Clinical Clerkship↗