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PubMed2003

Alcohol drinking as a predictor of intensive care and hospital mortality in general surgery: a prospective study.

AIMS: To analyse whether alcohol drinking increases admission to intensive care and in-hospital mortality in general surgery. DESIGN AND PARTICIPANTS: A prospective cohort study on a consecutive series of 1505 hospitalized patients in a Service of General Surgery of a tertiary hospital. MEASUREMENTS: Drinking pattern was defined by quantity, frequency and volume of drinking. Information on relevant confounders was obtained: smoking, body mass index, nutritional status (measured by serum albumin), cholesterol and its fractions, severity of the underlying disease and all therapeutic measures. Multivariate logistic regression was applied to assess the relationship between drinking and both admission to intensive care and in-hospital death. RESULTS: Twenty-nine (1.9%) patients died and 33 (2.1%) were admitted to the intensive care unit (ICU). Drinking was heavier in men, patients without antecedents of cancer, with lower preoperative risk assessment scores, number of co-morbidities and age and higher serum albumin levels. After adjusting for age, severity of underlying disease, smoking and serum albumin, male drinkers of 72+ g/day had an increased risk of being admitted to ICU, the effect being stronger for week-day drinking (odds ratio, OR = 8.48; 95% confidence interval, CI = 1.68-42.8). A significant association was also seen between week-day drinking (72+ g/day) and death in men (OR = 7.19, 95% CI = 1.43-36.1). Numbers for women were too small to evaluate. CONCLUSION: Heavy drinking increases admission to intensive care and in-hospital mortality in hospitalized male patients undergoing general surgery procedures.

Alcohol Drinking↗
PubMed2003

Impact of an endovascular program on the operative experience of abdominal aortic aneurysm in vascular fellowship and general surgery residency.

BACKGROUND: This study was performed to determine the impact of an endovascular program (EVP) on open and endovascular abdominal aortic aneurysm (AAA) operations in a residency training institution. METHODS: Over an 8-year period ending in September 2001, hospital records of all patients undergoing open or endovascular AAA repair were retrospectively reviewed. Data were analyzed to determine the changing patterns of case volume, type of operative repair, and complexity of open repair with regards to the training of both general surgical chief residents and vascular fellows. RESULTS: A total of 849 AAA operations were performed during the study period. The initiation of the EVP in 1997 resulted in a steady increase in the total annual AAA cases (P < 0.05), due in part to an increase in endovascular AAA operations despite a decrease in the annual open AAA volume. EVP had a positive impact on the overall operative experience of vascular fellows owing to the large increase in their endovascular AAA experience (annual mean pre-EVP 3 +/- 0.8 versus post-EVP 47 +/- 9.6, P < 0.01). A significant reduction occurred in the vascular fellows' open AAA experience (annual mean pre-EVP 40 +/- 12.7 versus post-EVP 19 +/- 9.4, P < 0.05). EVP did not affect the endovascular AAA experience of general surgery chief residents (annual mean pre-EVP 1 +/- 0.8 versus post-EVP 3 +/- 1.5, not significant). A significant reduction occurred in chief residents' open AAA experience (annual mean pre-EVP 39 +/- 9.7 versus post-EVP 18 +/- 7.4, P < 0.05). EVP did not affect the operative experience of complex open AAA operations in either vascular fellows or general surgery residents. CONCLUSIONS: An endovascular program has a positive impact on the aortic aneurysm practice in an academic institution, as evidenced by the significant increase in annual endovascular AAA cases despite a decrease in open AAA operations. Although vascular fellows continued to maintain sufficient experience in both open and endovascular AAA operations, general surgery chief residents suffered a significant decrease in their open AAA experience. Further evaluation of the residency system is warranted to better optimize the training paradigm of both vascular fellowship and general surgery residency.

Aortic Aneurysm, Abdominal↗
PubMed1999

Applying risk assessment models in general surgery: effective risk stratification.

The risk of venous thromboembolism (VTE) in general surgery patients varies from 10-50% depending on the type of surgery and underlying patient risk factors. Despite the availability of effective antithrombotic therapies, thromboprophylaxis is substantially underused in the general surgical field. The development of risk assessment models (RAMs) that can accurately and prospectively categorize patients according to their thromboembolic risk level may lead to improved use of thromboprophylaxis. Several evidence-based RAMs are now available that include general surgery in their range of clinical categories, allowing patients to be stratified rapidly for thromboembolic risk. Therapeutic recommendations are included in some cases. Tailoring anticoagulant therapy according to risk of VTE should maximize the clinical benefit and cost-effectiveness of prophylaxis, and minimize the risk of bleeding complications. Further studies are required to validate novel RAMs in clinical practice, and to extend their scope to include patient groups with particular needs, such as those undergoing neurosurgical procedures.

Humans↗
PubMed2001

Training general surgery residents in pediatric surgery: A Canadian survey.

BACKGROUND/PURPOSE: The training of general surgeons in pediatric surgery is an important educational role of pediatric surgeons (PS). The authored surveyed this training process and the related expectations and perceptions of competence. METHODS: The authors surveyed all practicing members of the Canadian Association of Paediatric Surgeons (CAPS) in Canada, all general surgery program directors (PD), and all final year general surgery residents (GS). Questions included exposure to pediatric surgery, expected and perceived competence in managing common pediatric general surgical problems, and trainee practice intentions. RESULTS: Response rate to date was 51% from PS, 69% from PD, and 19% from GS. Sixty-seven percent of PS considered the exposure to pediatric surgery satisfactory, yet only 1 of 7 residents planning on pursuing general surgery felt adequately prepared. Trainees were expected to be competent in the conditions polled by 65% of PS and 74% of PD, yet only 38% of the trainees actually felt competent in them. The largest discrepancies were found for infant hernia, newborn colostomy, and cryptorchidism. Presence of a fellowship program and size of training program had no impact on perceived competence. CONCLUSIONS: Training of general surgeons in pediatric surgery varies across Canadian programs. Perceived resident competence often lags behind program and faculty expectations. These data can be used for directing educational priorities in general surgery programs.

Attitude of Health Personnel↗
PubMed2003

Decline in popularity of general surgery as a career choice in North America: review of postgraduate residency training selection in Canada, 1996-2001.

There has been a perception that fewer medical students are currently pursuing careers in general surgery. To investigate the validity of this premise we reviewed the Canadian Residency Matching Service (CaRMS) database from 1996 to 2001 and identified recent trends in graduates' selections. Three surgical specialties--general surgery, orthopedic surgery, obstetrics and gynecology--were chosen for analysis as "poor lifestyle" specialties. They were compared to anesthesia, diagnostic radiology, and ophthalmology, which were chosen as representative "good lifestyle" specialties. Linear regression and chi-square analyses were performed to identify significant changes in applications to each specialty. A negative trend in first-choice applications to all three "poor lifestyle" specialties was observed, whereas all three "good lifestyle" specialties experienced increased first-choice applicants. Potential factors influencing medical student residency selection are discussed, emphasizing the reduced number of first-choice applicants to general surgery.

Canada↗
PubMed1996

Cost-effectiveness of prophylactic anticoagulation prolonged after hospital discharge following general surgery.

OBJECTIVE: To evaluate the net clinical benefit and the economic burden of prophylactic anticoagulation prolonged after hospital discharge following general surgery. DESIGN: A cost-effective analysis representing the risks of developing symptomatic venous thromboembolism beyond the hospital stay, the risks of major bleeding, and the efficacy of treatment. Data were drawn from the literature. SUBJECTS: A hypothetical cohort of 10,000 patients discharged from the hospital after general surgery (gastrointestinal, gynecologic, urologic, or vascular surgery). INTERVENTIONS: We compared 2 strategies: (1) prolonged self-administered prophylactic low-dose low-molecular-weight heparin during 4 weeks after discharge from the hospital and (2) anticoagulant therapy with heparin started immediately after the first clinically overt venous thromboembolism. MAIN OUTCOME MEASURES: The number of venous thromboembolisms prevented, the number of major bleeding events induced, and the average direct costs. RESULTS: Prophylactic low-molecular-weight heparin was an effective therapy. Depending on the rate of venous thromboembolism (0.06% to 0.18% per week), this strategy prevented 19 to 58 venous thromboembolisms for a cohort of 10,000 patients treated, more than the number of anticoagulation-related complications (n = 10). Its marginal costs, however, exceeded $2.5 million (US dollars) for 10,000 patients. As the weekly rate of venous thromboembolism increased, prophylactic low-molecular-weight heparin became more cost-effective, with a marginal cost-effectiveness ratio per venous thromboembolism prevented ranging from $135,903 (rate of venous thromboembolism, 0.06% per week) to 45,353 (rate of venous thromboembolism, 0.18% per week). CONCLUSION: Although prolonged prophylactic anticoagulation after hospital discharge for general surgery is effective in preventing venous thromboembolism, we believe that its marginal costs are too high to recommend its indiscriminate use.

Anticoagulants↗
PubMed1993

Do general surgery residency programs adequately train surgeons to perform anorectal surgery?

The management of anorectal disease remains a major component in the practice of the general surgeon. To assess the adequacy of general surgery residencies in addressing this educational need, data were obtained from the Residency Review Committee (RRC) for surgery on the anorectal experience of all graduating residents in accredited United States programs for a recent five-year period (1987-1991). The mean number of anorectal procedures in which a resident participated throughout the residency was 30.0. This is then further subdivided by type of procedure. It is concluded that general surgery residency programs tend to provide an inadequate training experience in anorectal surgery.

Anal Canal↗
PubMed1990

The future of general surgery. AMA council on long range planning and development.

During the past several years, the American Medical Association's Council on Long Range Planning and Development has identified trends in the environment of medicine that are likely to affect physicians, their practices, and the provision of medical care in the future. In the course of its environmental analysis studies, the Council has recognized that each medical specialty is uniquely subject to anticipated changes in the environment of medicine. As part of an ongoing series of analyses prepared by the Council, this report focuses on environmental trends that are likely to influence the practice of general surgery. The report outlines the current state of general surgery, the forces for change in the environment, and the implications regarding these changes. The Council concludes that there are certain challenges and many positive indicators for the future of general surgery.

American Medical Association↗
PubMed2000

General surgery program directors' perceptions of the match.

To identify expectations of general surgery program directors (PDs) for recruitment behavior, and to document the experiences, perceptions, and ethical dilemmas they experienced with the 1998 National Resident Matching Program (NRMP).Two hundred sixty-five general surgery PDs were asked to complete a 30-item written questionnaire. Questions inquired about PD perceptions of students' interviewing practices, how communication with applicants is conducted and interpreted, and overall perceptions of the match.A total of 77.7% of PDs responded. A total of 44% of PDs found nothing wrong with students interviewing in multiple specialties and conceded legitimate reasons for doing so; yet, 75% of PDs felt this practice negatively affected students' rank order. A total of 46.6% of programs told students to keep in touch to be ranked; only 8.7% of PDs believed students' stated interest, and 76.6% of PDs said these affirmations had no effect on students' rank. A total of 36.5% of PDs felt students made informal commitments to them, and 90.4% felt students at least sometimes lied to them. A total of 51.7% of PDs felt the match was a reasonable process that needed no changes.As long as the stakes are high and there are no repercussions for unethical behaviors and practices during residency recruitment, gamesmanship will continue to be the accepted culture.

Journal Article↗
PubMed1998

General surgery in the year 2000: looking to the future.

The goal of the 1997 Canadian Association of General Surgeons presidential address was to predict the future for general surgery in Canada in an optimistic fashion. However, on the basis of its current status, the vision for general surgery also includes the reality of the problems that the specialty will face. General surgeons must become advocates so as to help resolve these problems for the community and for their patients.

Ambulatory Surgical Procedures↗
PubMed1996

Complications of laparoscopic general surgery.

With the growth of laparoscopic general surgery, both minor and major complications are being encountered. This article discusses complications related to operative laparoscopy, including those associated with access techniques and the pneumoperitoneum. Complications specific to certain procedures, including laparoscopic cholecystectomy, appendectomy, colon resection, anti-reflux surgery, and herniorrhaphy, are also discussed in detail.

Anesthesia, General↗
PubMed2003

Robotics and general surgery.

Robotics are now being used in all surgical fields, including general surgery. By increasing intra-abdominal articulations while operating through small incisions, robotics are increasingly being used for a large number of visceral and solid organ operations, including those for the gallbladder, esophagus, stomach, intestines, colon, and rectum, as well as for the endocrine organs. Robotics and general surgery are blending for the first time in history and as a specialty field should continue to grow for many years to come. We continuously demand solutions to questions and limitations that are experienced in our daily work. Laparoscopy is laden with limitations such as fixed axis points at the trocar insertion sites, two-dimensional video monitors, limited dexterity at the instrument tips, lack of haptic sensation, and in some cases poor ergonomics. The creation of a surgical robot system with 3D visual capacity seems to deal with most of these limitations. Although some in the surgical community continue to test the feasibility of these surgical robots and to question the necessity of such an expensive venture, others are already postulating how to improve the next generation of telemanipulators, and in so doing are looking beyond today's horizon to find simpler solutions. As the robotic era enters the world of the general surgeon, more and more complex procedures will be able to be approached through small incisions. As technology catches up with our imaginations, robotic instruments (as opposed to robots) and 3D monitoring will become routine and continue to improve patient care by providing surgeons with the most precise, least traumatic ways of treating surgical disease.

Adrenalectomy↗
PubMed1989

The future of general surgery. Council on Long Range Planning and Development.

During the past several years, the American Medical Association's Council on Long Range Planning and Development has identified trends in the environment of medicine that are likely to affect physicians, their practices, and the provision of medical care in the future. In the course of its environmental analysis studies, the Council has recognized that each medical specialty is uniquely subject to anticipated changes in the environment of medicine. As part of an ongoing series of analyses prepared by the Council, this report focuses on environmental trends that are likely to influence the practice of general surgery. The report outlines the current state of general surgery, the forces for change in the environment, and the implications regarding these changes. The Council concludes that there are certain challenges and many positive indicators for the future of general surgery.

Adult↗
PubMed1994

[Efficacy and tolerance of Fraxiparine in the prevention of deep vein thrombosis in general surgery performed with medullar conduction anesthesia].

From 1989 to 1991, 480 patients undergoing general surgery under epidural anaesthesia were included in a multicentre, comparative, randomized, open-study designed to assess whether calcium nadroparin (Fraxiparine), one daily subcutaneous injection of 0.3 mL, i.e. 3,075 anti Xa IU per day, is more efficiency and better tolerated than a non-fragmented standard heparin (Calciparine), one subcutaneous injection of 0.2 mL t.i.d. 15,000 IU per day, for the prevention of postoperative deep vein thrombosis (DVT). The 480 patients, treated in 78 centres, were randomized in two groups (Fraxiparine, n = 241; Calciparine, n = 239). In both groups, treatment was started two hours after the end of the surgical procedure. Hernia repair and prostatic surgery accounted for 60% of operations. Thromboembolic events were detected by clinical examination performed at regular time intervals and by a systematic exam (doppler and rheoplethysmography or ultrasonogram) at the end of the treatment. Both agents demonstrated a similar efficiency. There was only one case of DVT, confirmed by phlebography in the Fraxiparine group. Tolerance was good in both groups. The proportion of patients requiring a transfusion was low (3% in each group). Hematuria was relatively frequent (33% in the Fraxiparine group and 28% in the Calciparine group), however these rates were related to prostatic and urinary incontinence surgery. This study, including a wide series of patients undergoing general surgery under epidural anaesthesia, demonstrates that efficiency and tolerance of one daily injection of Fraxiparine are similar to those of three daily injections of Calciparine. It it concluded that Fraxiparine improves of the patient's comfort and decreases the nursing work load.

Adult↗