Surgical Colleague Research Articles

“I JUST WANTED TO GET THE PAIN OUT OF THE WAY”: WHY PEOPLE WITH SIGNS AND SYMPTOMS OF SUSPECTED CAUDA EQUINA SYNDROME ATTEND THE EMERGENCY DEPARTMENT

Purpose and backgroundCauda Equina Syndrome (CES), a rare (<1 per 100,000) and potentially devasting condition, involves compression of the lumbosacral nerve roots. If not quickly identified and treated, it can lead to lasting disability, and high medicolegal costs (>£186 million in the decade to 2018). This study identified why people with suspected CES attend the emergency department (ED) and explored any delays in attending.Methods and ResultsThe design was a secondary analysis of a qualitative dataset comprising patients with back pain who attended the ED, undertaken using an interpretivist approach. Fourteen patients (8M:6F, aged 23–63 years) with suspected CES were purposively sampled from 4 EDs (2 Northern and 2 Southern) in England between August and December 2021. Semi-structured interviews were conducted online, audio-recorded, transcribed verbatim and analysed thematically.Acopia with pain was the biggest factor in a participant's decision to attend the ED, along with the need for a diagnosis. This pain was the worst ever experienced and debilitating, leaving people unable to cope and desperate for relief. 12/14 were advised to attend the ED following identification of red flags by: GPs (n=9); physiotherapists (n=2); surgical colleague (n=1); and 111 (n=1). Factors such as guilt, previous experience of being disregarded, and symptom misattribution were seen to cause delays in seeking care.ConclusionThis paper revealed a disconnect between the priorities of patients and clinicians prior to attending the ED. Clinicians need to validate the pain experience, communicate clearly why signs and symptoms are concerning, and convey the urgency and potential impact of CES.Conflicts of interestNoneSources of fundingFunding for primary data: Health Education England & NationalInstitute of Health and Care Research (ICA-CDRF-2018-04-ST2-040)

Perfect Preparation.

Perfect Preparation.

Interdisciplinary Management of Extramammary Paget's Disease Using Mohs Micrographic Surgery With Frozen Section Cytokeratin-7 Immunostains

ObjectiveTo describe local recurrence rates and patient-reported outcomes when Mohs micrographic surgery with cytokeratin-7 immunostains (MMS-CK7) is included in the interdisciplinary management of extramammary Paget's disease (EMPD) MethodsA retrospective study was conducted of EMPD treated with MMS-CK7 as part of an interdisciplinary team at an academic medical center between 2009 and 2016. Local recurrence rates and patient-reported outcomes were determined by record review and patient surveys. ResultsTwenty tumors in 19 patients were treated using MMS-CK7. After MMS-CK7 defined clear microscopic margins, 75% (15/20) of tumors underwent excision or reconstruction by a surgical colleague. Internal malignancy screening was performed by multiple specialties in 17 patients, with 1 associated malignancy of prostate cancer detected. No local recurrence was detected with a mean follow-up of 75.2 months. Most patients were satisfied with appearance (18/19, 95%) and function (16/19, 84%) after surgery. ConclusionInterdisciplinary teams that include MMS-CK7 can treat EMPD with low local recurrence rates, high patient satisfaction, and thorough internal malignancy screening.

Outcomes of Rhegmatogenous Retinal Detachment Repair When Comparing Surgeon Continuity in a Team-Based Practice

To facilitate timely surgery and efficient use of operating room time, our practice uses a team-based approach so patients may undergo primary rhegmatogenous retinal detachment (RRD) surgery with a different surgeon instead of the diagnosing surgeon. This was a retrospective cohort study of 331 eyes that underwent RRD surgery. Patients were divided into two groups: RRD surgery performed by the diagnosing surgon, and RRD surgery performed by a different surgeon. Of 331 eyes, 200 eyes (60.4%) were repaired by the diagnosing surgeon and 131 eyes (39.6%) were repaired by a different surgeon. Primary anatomic success (PAS) rates at 3 months postoperatively were equivalent between the two groups (87.0% and 87.8% in the diagnosing surgeon and different surgeon groups, respectively [P = .83]). There was no significant difference in preoperative (P = .08) or final (P = .28) visual acuity between the groups. Time between diagnosis and RRD repair was shorter in the different surgeon group (median of 1.5 days [IQR: 1.0-3.6] in the surgeon group versus 2.2 days [IQR: 0.8-5.7] in the diagnosing surgeon group) (P = .03). Logistic regression analysis gave no evidence to suggest that PAS rates depended on day of week, time of day surgery was performed, group, or the interaction between those factors (P = .93). Visual and anatomic success in RRD repair are equivalent when surgery is performed by either the diagnosing surgeon or a surgical colleague because time to surgery is reduced. Neither time of day nor day of the week had any influence on the outcomes. [Ophthalmic Surg Lasers Imaging Retina. 2021;52:560-566.].

Video-Based Coaching: Current Status and Role in Surgical Practice (Part 1) From the Society for Surgery of the Alimentary Tract, Health Care Quality and Outcomes Committee

Patient safety and outcomes are directly related to surgical performance. Surgical training emphasizes the importance of the surgeon in determining these outcomes. After training is complete, there is a lack of structured programs for surgeons to audit their skills and continue their individual development. There is a significant linear relationship between surgeon technical skill and surgical outcomes; however, measuring technical performance is difficult. Video-based coaching matches an individual surgeon in practice with a surgical colleague who has been trained in the core principles of coaching for individualizing instruction. It can provide objective assessment for teaching higher-level concepts, such as technical skills, cognitive skills, and decision-making. There are many benefits to video-based coaching. While the concept is gaining acceptance as a method of surgical education, it is still novel in clinical practice. As more surgeons look towards video-based coaching for quality improvement, a consistent definition of the program, goals, and metrics for assessment will be critical. This paper is a review on the status of the video-based coaching as it applies to practicing surgeons.

The Surgical Lifeline: Intraoperative Consultation.

The Surgical Lifeline: Intraoperative Consultation.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

Endoscopic gastric plication for the treatment of GERD and underlying class I obesity.

Violation of Aseptic practices in Operation Theater

Patient wellbeing has become a health policy need the world wide. Recognizing that 'to blunder is human' has prompted endeavors to plan frameworks and decides that point of confinement the limit with respect to singular prudence and subsequently diminish clinical mistakes. Surgical colleague's practices have significance with respect to the nature of care among the patient whose experience any of surgery. Shockingly it is seen that the surgical group didn't rehearse well and furthermore didn't pursue the standards, for example, legitimate scouring, wearing careful gloves and blended utilization of sterile and unsterile instruments. So in the lieu of these mal-rehearses nature of care may bargain and furthermore significant reason for careful site disease? In results the dismalness and death rate may increment. The objective of asepsis and aseptic method is to avoid the exchange of microorganisms into the careful injury. Counteracting careful site tainting requires the endeavors of all prepared careful colleagues to utilize their insight and involvement with aseptic practices to give their patients ideal care bringing about positive careful results. Then again to switch the careful group towards the appropriate practices, it is have to give legitimate assets (place, person and money), preparing for surgical group and furthermore diminish the outstanding task at hand. Keywords : Aseptic practices, Operation Theater DOI : 10.7176/JHMN/68-13 Publication date: November 30 th 2019

Barriers to Performing Soft Tissue Reconstruction Procedures among Orthopedic Surgeons in Low- and Middle-income Countries: Results of a Surgical Skills Training Course.

Background:Appropriate management of soft tissue injury associated with orthopedic trauma is challenging in low- and middle-income countries (LMICs) due to the lack of available reconstructive surgeons. The Surgical Management and Reconstructive Training (SMART) course teaches orthopedic surgeons reconstructive techniques aimed at improving soft tissue management. This study aims to identify additional barriers to implementing these techniques for surgeons in LMICs who have attended SMART courses.Methods:This is a mixed-methods study including a Likert-scale-based survey administered to 150 surgeons from LMICs attending the 2018 SMART courses in Tanzania and San Francisco and key informant interviews with 20 surgeons who perform soft tissue coverage procedures.Results:In surveys, respondents reported inadequate local plastic surgeon availability for lower extremity fracture requiring muscle flaps (88%). Surgeons agreed that flap surgeries are important for patients with significant soft tissue injury following open fractures (97%). They reported inadequate access to instruments, such as dermatomes (59%) and Humby knives (32%), and senior-level support (31%). Fewer than half of surgeons with flap experience (n = 85) felt confident in training peers (45%). In interviews, delays in returning patients to operating rooms were frequently cited as a barrier (90%).Conclusions:Our study demonstrates that soft tissue procedures are perceived as a high priority among orthopedic surgeons, but there are multiple barriers, including a lack of plastic surgeons, and many modifiable barriers including a lack of surgical equipment, peer training, and senior colleague support.

Helen Brooke Taussig: preserver of babies’ hearts and limbs

As a paediatric cardiologist in Depression-era America, Helen Brooke Taussig (1898–1986) saw many “blue” babies, their blood starved of oxygen as it failed to circulate properly through the lungs. The infants gasped for breath after the least exertion and usually died at an early age. After studying the condition, which was caused by a cluster of congenital heart defects, Taussig proposed to her surgical colleague at Johns Hopkins University, Alfred Blalock (1899–1964), that it might be alleviated by a procedure to divert another artery to the lungs. They first did the Blalock–Taussig shunt on a baby in 1944, and since then many parents have had the joy of seeing their babies turn pink and healthy almost overnight. Women making medical history: introducing A Woman's PlaceIn December, 2017, The Lancet issued a call for papers for its special theme issue on women in science, medicine, and global health .1 The Comment outlined the gender inequalities in medicine that still persist, long after many overt barriers to women's participation have fallen. While that theme issue will be forward-looking, I believe we can also gain insights from looking to the past for examples of women who have made their mark against the odds, and by asking what it was about their particular circumstances that enabled them to do so. Full-Text PDF Marie Boivin: from midwife to gynaecologistThe authoritative Traité pratique des maladies de l'uterus et de ses annexes, published in Paris in 1833, was one of the most forward-thinking gynaecological texts of 19th-century Europe. It was more specific than previous texts, such as the British physician Marshall Hall's Commentaries on Some of the More Important of the Diseases of Females of 1827, and it focused on the reproductive organs as a system rather than simply in relation to childbirth. This textbook was based not on previous authorities but on first-hand case studies and autopsies, including the first account of the surgical removal of a cancerous cervix. Full-Text PDF

'Colleaguography' in place of cholangiography, to prevent bile duct injury during laparoscopic cholecystectomy

Bile duct injury (BDI) is not uncommon during laparoscopic cholecystectomy (LC). Intra-operative cholangiography (IOC) has been recommended to reduce the risk of BDI during LC. Facilities for IOC are, however, scarcely available in India. The author suggests ‘in vicinity colleaguography’ (IVC) – opinion of a surgical colleague in vicinity – as an easy alternative to IOC.

Academics and training of residents in pandemic norm of physical distancing and restrained surgeons – Remembering Osler and Halsted!

Academics and training of residents in pandemic norm of physical distancing and restrained surgeons – Remembering Osler and Halsted!

Ovarian Cancer Surgery in Australia and New Zealand: A Survey to Determine Changes in Surgical Practice Over 10 Years.

This study aimed to survey all practicing certified gynecological oncologists (CGOs) in Australia and New Zealand to determine their current surgical practice for primary advanced epithelial ovarian cancer (EOC) and compare the findings with an identical survey conducted 10 years previously. A questionnaire was e-mailed to all 53 practicing CGOs in Australia and New Zealand in July 2017 assessing their definition of optimal debulking for EOC, their use of neoadjuvant chemotherapy, and the surgical procedures they use to achieve cytoreduction. Results were compared with an identical study performed in 2007 using χ and logistic regression analysis. Response rate was 89% (47/53). A higher percentage of patients received neoadjuvant chemotherapy before surgery in 2017 than in 2007 (43% vs 16%, respectively). In 2017, CGOs were more likely to define optimal debulking as zero residual disease (R0; 21/44 [48%] vs 6/34 [18%], P < 0.001). To achieve this, CGOs were significantly more likely to independently perform stripping/resection of the diaphragm (44/47 [94%] vs 15/34 [44%], P < 0.001) and, with assistance from surgical colleagues, perform resection of upper para-aortic lymph nodes (39/46 [85%] vs 21/34 [62%], P = 0.02) and parenchymal liver metastases (30/46 [65%] vs 13/34 [38%], P = 0.02). They were now less likely to resect/reimplant the ureter without assistance (23% vs 53%, P = 0.01). A surgeon's definition of optimal debulking as R0 was significantly associated with a high use of neoadjuvant chemotherapy (in ≥50% of patients). Certified gynecological oncologists' definition of optimal debulking for primary EOC is more likely to be R0 in 2017 than in 2007. Radical abdominal surgery was performed more often in 2017, requiring assistance by a surgical colleague in many cases. An increased use of neoadjuvant chemotherapy was the only factor significantly associated with CGOs' definition of optimal debulking as R0.

A Rare Case of Anterior Sacral Meningocele (ASM) in a Young Patient

We report a 24-year-old male who presented with abdominal distension, constipation and left sided groin pain. CT and MRI of the abdomen/spine were performed which showed a large anterior sacral meningocele occupying most of the pelvic and abdominal cavity and displacement of their respective contents. Initially a posterior approach with lumbosacral laminectomy (L5 - S4) was performed. The ostium of the meningocele was identified with several nerve roots identified passing through, adjacent and into the defect. As nerve roots traversed the ostium, watertight closure was not feasible without sacrificing nerve roots. Subsequent MRI demonstrated recurrence of approximately 60% of the anterior sacral meningocele. We therefore opted to approach the ASM anteriorly via an anterior approach with the help of colorectal surgical colleague. The ASM was completely embedded within the sigmoid and upper to mid rectal mesentry, with its own vascular supply to the thick walled capsule. This case highlights the need for a combined approach due to the incorporation of the pseudomeningocele into the omentum with the development of its own blood supply.

Success is not final and failure is not fatal.

DOI: 10.1200/JCO.2014.55.2828 We cannot always anticipate how patients will respond to information we present them—even startlingly good news. Clinical oncology by its very nature is fraught with emotion and is full of uncertainty and ambiguity. Conveying uncertainty remains a major component of an oncologist’s clinical work. The fear, angst, and sometimes anger encountered with the development or progression of metastatic disease are common emotions in clinic. We are less familiar with the uncertainty and accompanying dilemmas presented by successful therapy in the metastatic setting. For the last 3 years, I have been treating Mrs P, a woman with multifocal metastatic disease. I have always been direct with her regarding the situation and have talked frankly about the fact that her sarcoma is not curable and treatment options limited. I am quite sure that she has no doubts about the palliative aims of treatment. On this particular day, she was due to see the nurse practitioner, so when I walked into the room, she sensed that it was because I had bad news. She is intelligent, sophisticated, and forthright and does not hesitate to articulate her opinions. On this busy clinic day, it was an all too familiar conversation regarding the development of recurrent disease, the uncertainties of trial participation, and the time commitment involved. For me, this was a wellrehearsed and easily delivered dialogue. Mrs P, who was also a master of communication skills, detected uncertainty in the nurse practitioner’s approach and recognized that my unexpected appearance signaled trouble. She treated the medical system with suspicion and at times with disdain. She expressed her thoughts about my treatment recommendation and the proposed clinical trial with candor and directness. In the end, she opted for the trial, despite the required effort and commitment. She did well. Months went by and restaging scans showed continued improvement. She tolerated the intravenous drug well. She and her husband were delighted. Her visits became routine and straightforward, the results consistently good. I would often quote my surgical colleague’s adage to her: “A quick visit is always a good visit.” On several occasions, she mentioned that she did “not want to be on this treatment forever.” I stuck to my narrative that, in this case, prolonged chronic therapy would be the best-case option for someone with her advanced stage of disease. After 1.5 years on therapy, restaging scans demonstrated a radiologic complete response. She tolerated the drug extremely well. So at this point, we began to discuss again the distance she had to travel to receive treatment and how long she ought to continue on the drug. Both the patient and her husband were getting tired of the journey and the uncertainty regarding the length of therapy. It was clear to all of us that she could not receive the investigational agent off trial. We had looked into that option with her, but there were almost insurmountable hurdles in getting this trial open (for a rare disease) at her local hospital. So Mrs P’s basic choice was to continue to travel to receive her maintenance therapy or stop. Her question remained: “How long must I continue?” Mrs P and her husband knew that stopping treatment would likely mean return of cancer. Although it was successful, we harbored no fantasy that therapy was curative, and it was this critical fact that she found unbearable. Her questions exposed other concerns, both financial and personal. From that point on, clinic visits became increasingly more challenging and testy. We would discuss the excellent scan results, continuing treatment or stopping, and then end the conversation by acknowledging the lack of data regarding outcome. We spoke of other patients who had continued on chronic therapy for metastatic disease with all the associated physical and emotional challenges of such protracted treatment. She appreciated the benefit she had obtained, and I would remind her that tragically other patients were not as fortunate. I could appreciate her concerns, the disease was uncurable, and she was essentially in limbo. Yes, the trial medication was good and she had derived clear benefit, but the choice was to continue with therapy indefinitely or stop. She was frustrated and derived no comfort from hearing other patients’ stories or any anecdotal evidence I could provide. More than 2 years after starting therapy, she returned with her husband for another routine scan. And once again, the scan showed a maintained radiologic complete response. I thought JOURNAL OF CLINICAL ONCOLOGY A R T O F O N C O L O G Y VOLUME 32 NUMBER 30 OCTOBER 2

Advances in the Field of Interventional Cardiology: Spotlight On Transcatheter Aortic Valve Implantation

Q Can you tell us a little about your career background? I trained in medicine in Bristol and then did my cardiology training in Oxford and Cardiff before doing a PhD in endothelial function at the University Hospital of Wales. I then came to King’s for my interventional training, leaving transiently for an international fellowship in Aalst in Belgium. This was a British Heart Foundation-funded fellowship with Bernard de Bruyne and William Wijns. I then returned to King’s and was appointed as a consultant in 2003. I helped set up the primary angioplasty program and then the transcatheter aortic valve implantation (TAVI) program, the latter with my cardiothoracic surgical colleague Olaf Wendler. I was appointed Clinical Lead at King’s in 2007 and Clinical Director of Cardiovascular Services in 2012. Q What do you believe has been the biggest advance in interventional cardiology in the last 5 years? The single biggest advance in the last 5 years would have to be transcatheter heart valve therapy. Most people would agree that that is the area that has advanced the most. This includes TAVI, but also all of the things that have come along with the TAVI process in terms of treating other valves and the increased awareness of aortic valve disease.

PWE-201 Techniques for removal of polyps from the right colon: how are we doing them?

IntroductionPolypectomy is a commonly performed therapeutic intervention and all colonoscopists should be able to perform the procedure safely and effectively. Complications can include perforation and bleeding. Practice has evolved considerably...

Joseph Murray: innovative surgeon and pioneer of transplantation

In an age when expertise is ever more narrowly focused, the notion of training in one subspecialty, moving to another, doing research that will earn a Nobel Prize, then switching back to the original sounds distinctly fanciful. Yet in the mid-1900s Joseph Murray—by training a plastic surgeon but celebrated as the Nobel Prize winning pioneer of kidney transplantation—did precisely that. As his late friend and Boston surgical colleague Francis Moore is said to have commented, “Joe's the only guy who ever won a Nobel Prize for pursuing a hobby.” An overstatement, of course; but looking back over Murray's career, you can see what he was getting at.

Sir Astley Paston Cooper

Sir Astley Paston Cooper

James Scott Robson

Clinician who ended hepatitis epidemics in dialysis units In 1958 dialysis was beginning to be used in the treatment of acute renal failure, and James Scott Robson and his surgical...