Care of the bariatric surgery patient in the emergency department

Obesity has reached epidemic proportions in the United States, with an estimated 50% of adults meeting the definition of being overweight. As this condition has become more prevalent, bariatric surgery has become an increasingly accepted form of treatment of the severely obese. Patients who have had bariatric surgery are presenting more commonly to Emergency Departments as a result. This article will review the most common bariatric surgery procedures, the complications that can arise post-operatively, and the approach to the assessment and management of the bariatric surgery patient in the Emergency Department.

Learning styles vary among general surgery residents: analysis of 12 years of data

PURPOSE: Understanding the learning styles of individuals may assist in the tailoring of an educational program to optimize learning. General surgery faculty and residents have been characterized previously as having a tendency toward particular learning styles. We seek to understand better the learning styles of general surgery residents and differences that may exist within the population. METHODS: The Kolb Learning Style Inventory was administered yearly to general surgery residents at the University of Cincinnati from 1994 to 2006. This tool allows characterization of learning styles into 4 groups: converging, accommodating, assimilating, and diverging. The converging learning style involves education by actively solving problems. The accommodating learning style uses emotion and interpersonal relationships. The assimilating learning style learns by abstract logic. The diverging learning style learns best by observation. Chi-square analysis and analysis of variance were performed to determine significance. RESULTS: Surveys from 1994 to 2006 (91 residents, 325 responses) were analyzed. The prevalent learning style was converging (185, 57%), followed by assimilating (58, 18%), accommodating (44, 14%), and diverging (38, 12%). At the PGY 1 and 2 levels, male and female residents differed in learning style, with the accommodating learning style being relatively more frequent in women and assimilating learning style more frequent in men (Table 1, p < or = 0.001, chi-square test). Interestingly, learning style did not seem to change with advancing PGY level within the program, which suggests that individual learning styles may be constant throughout residency training. If a resident's learning style changed, it tended to be to converging. In addition, no relation exists between learning style and participation in dedicated basic science training or performance on the ABSIT/SBSE. CONCLUSIONS: Our data suggests that learning style differs between male and female general surgery residents but not with PGY level or ABSIT/SBSE performance. A greater understanding of individual learning styles may allow more refinement and tailoring of surgical programs.

Laparoscopic surgery impairs tissue oxygen tension more than open surgery

BACKGROUND: Wound infection remains a common and serious complication after colonic surgery. Although many colonic operations are performed laparoscopically, it remains unclear whether this has any impact on the incidence of wound infection. Subcutaneous tissue oxygenation is an excellent predictor of surgical wound infection. The impact of open and laparoscopic colonic surgery on tissue oxygenation was compared. METHODS: Fifty-two patients undergoing elective open and laparoscopic left-sided colonic resections were evaluated in a prospective observational study. Anaesthesia management was standardized and intraoperative arterial partial pressure of oxygen was kept at 150 mmHg in both groups. Oxygen tension was measured in the subcutaneous tissue of the right upper arm. RESULTS: At the start of surgery subcutaneous tissue oxygen tension (PsqO(2)) was similar in both groups (mean(s.d.) 65.8(17.2) and 63.7(23.6) mmHg for open and laparoscopic operations respectively; P = 0.714). Tissue oxygen remained stable in the open group, but dropped significantly in the laparoscopic group during the course of surgery (PsqO(2) after operation 53.4(12.9) and 45.5(11.6) mmHg, respectively; P = 0.012). CONCLUSION: Laparoscopic colonic surgery significantly decreases PsqO(2), an effect that occurs early in the course of surgery. As tissue oxygen tension is a predictor of wound infection, these results may explain why the risk of wound infection after laparoscopic surgery remains higher than expected.

Nitric oxide synthase in critically ischaemic muscle and alterations in isoform expression during revascularization surgery

BACKGROUND: Dysfunction of the nitric oxide pathway is implicated in peripheral arterial disease. Nitric oxide synthase (NOS) isoforms and NOS activity were studied in muscle from patients with critical leg ischaemia (CLI). Alterations in NOS during revascularization surgery were also assessed. METHODS: Muscle biopsies were taken from patients with CLI undergoing amputation and also from patients undergoing femorodistal bypass at the start of surgery, after arterial clamping and following reperfusion. The presence of NOS within muscle sections was confirmed using reduced nicotinamide adenine dinucleotide phosphate diaphorase histochemistry. NOS isoform distribution was studied by immunohistochemistry. NOS mRNA and protein levels were measured using real-time reverse transcriptase-polymerase chain reaction and western blotting. NOS activity was assessed with the citrulline assay. RESULTS: All three NOS isoforms were found in muscle, associated with muscle fibres and microvessels. NOS I and III protein expression was increased in CLI (P = 0.041). During revascularization, further ischaemia and reperfusion led to a rise in NOS III protein levels (P = 0.008). NOS activity was unchanged. CONCLUSION: Alterations in NOS I and III occurred in muscle from patients with CLI and further changes occurred during bypass surgery.

[Goiter and nodular thyroid disease: clinical guidelines for diagnosis and treatment. (Waiting? Hormone therapy? Surgery? radioiodine?)]

Nodular thyroid disease is a common problem. We present clinical guidelines for the management of patients with thyroid nodules, multinodular goiters and thyroid cysts for use by primary physicians. In the initial evaluation ultrasonography of the thyroid and fine-needle aspiration biopsy (FNAB) is recommended. FNAB has become the cornerstone in the evaluation of solitary thyroid nodules, cysts and dominant nodules within multinodular goiters. If the procedure is done properly, it should have a false-negative rate of less than 5% and a false-positive rate of not more than 1%. Thyroid radionuclide scans are less frequently used in the initial evaluation of a nodular goiter. Surgery is the primary therapy for patients with nodular thyroid disease. Other available treatment options are radioiodine and TSH-suppression with thyroxine. The main indications for surgery in euthyroid patients with thyroid nodule or with nontoxic multinodular goiter are recently documented or suspected malignancy, compression of the trachea and esophagus, significant growth of the nodule, recurrence of a cyst after aspiration, neck discomfort and cosmetic concern.

CT radiation dose for computer-assisted endoscopic sinus surgery: dose survey and determination of dose-reduction limits

BACKGROUND AND PURPOSE: Computer-assisted navigation is increasingly used in functional endoscopic sinus surgery (FESS) to prevent injury to vital structures, necessitating preparative CT and, thus, radiation exposure. The purpose of our study was to investigate currently used radiation doses for CT in computer-assisted navigation in sinus surgery (CAS-CT) and to assess minimal doses required. MATERIALS AND METHODS: A questionnaire inquiring about dose parameters used for CAS-CT was sent to 30 radiologic institutions. The feasibility of low-dose registration was tested with a phantom. The influence of CAS-CT dose on technical accuracy and on the practical performance of 5 ear, nose, and throat (ENT) surgeons was evaluated with cadaver heads. RESULTS: The questionnaire response rate was 63%. Variation between minimal and maximal dose used for CAS-CT was 18-fold. Phantom registration was possible with doses as low as 1.1 mGy. No dose dependence on technical accuracy was found. ENT surgeons were able to identify anatomic landmarks on scans with a dose as low as 3.1 mGy. CONCLUSIONS: The vast dose difference between institutions mirrors different attitudes toward image quality and radiation-protection issues rather than being technically founded, and many patients undergo CAS-CT at higher doses than necessary. The only limit for dose reduction in CT for computer-assisted endoscopic sinus surgery is the ENT surgeon's ability to cope with impaired image quality, whereas there is no technically justified lower dose limit. We recommend, generally, doses used for the typical diagnostic low-dose sinus CT (120 kV/20-50 mAs). When no diagnostic image quality is needed, even a reduction down to a third is possible.

[Stress tolerance and quality of life--effect of a comprehensive ambulatory rehabilitation program for patients with chronic heart failure]

Chronic heart failure (CHF) impairs quality of life (QoL) much stronger than other chronic diseases. The objective of this evaluation was to assess the effect of a new integrated comprehensive outpatients rehabilitation program on somatic parameters and quality of life in 51 patients with stable CHF. After rehabilitation, left ventricular ejection fraction, NYHA class, and parameters of sub-maximum and maximum exercise capacity improved significantly between 11 and 20%, and 6-minute walking distance by 58% on average (p < 0.0001). Non-disease specific QoL (Short Form-36 questionnaire) improved in only 2 of 8 subscales (physical functioning [effect size 0.38, p < 0.001], and role functioning [effect size 0.17, p < 0.05]), and a mental component score [effect size 0.47, p < 0.0001]. Disease-specific QoL (Minnesota Living with Heart Failure questionnaire) improved in terms of sum score [effect size 0.24, p < 0.0001], and physical component score [effect size 0.35, p < 0.0001]. Improvement in exercise capacity correlated significantly with improvements in parameters of disease-specific QoL.

Comparison of periapical radiography and limited cone-beam tomography in posterior maxillary teeth referred for apical surgery

This study compared periapical (PA) radiography and cone-beam tomography (CBT) for preoperative diagnosis in posterior maxillary teeth of consecutive patients referred for possible apical surgery. Images were concurrently analyzed by an oral radiologist and an endodontist to reach consensus in interpretation of the radiographic findings. The final material included 37 premolars and 37 molars with a total of 156 roots. CBT showed significantly more lesions (34%, p < 0.001) than PA radiography. Detecting lesions with PA radiography alone was most difficult in second molars or in roots in close proximity to the maxillary sinus floor. Additional findings were seen significantly more frequently in CBT compared with PA radiography including expansion of lesions into the maxillary sinus (p < 0.001), sinus membrane thickening (p < 0.001), and missed canals (p < 0.05). The present study highlights the advantages of using CBT for preoperative treatment planning in maxillary posterior teeth with apical pathology.