The American Journal of Surgery

Editorial Board

2012-02-01

Carotid stenosis: change of treatment plan based on repeat duplex ultrasonography

Brett E. Grizzell, Alex D. Ammar, Stephen D. Helmer — 2011-07-26

Abstract: Background: This study was conducted to evaluate the change in the treatment plan observed when clinical decisions are made based on initial carotid duplex ultrasonography (DU) performed at an outside center before surgical consultation versus those made based on DU performed in a dedicated vascular laboratory. Methods: A prospective study of patients who underwent initial DU at an outside facility and repeat DU in a dedicated vascular laboratory for evaluation of carotid stenosis was performed. Initial DU was compared with repeat DU to evaluate clinical impact. Results: Ninety-six consecutive patients were evaluated. Disagreement between initial DU and repeat DU was observed in 27.1% of patients. This disagreement led to a change of treatment plan in 23 of 146 (15.8%) carotid arteries studied. Conclusions: Reliance on 1 DU in clinical practice, when performed outside a dedicated vascular laboratory, may lead to both unnecessary surgery and missed opportunities for surgery to prevent stroke.

The surgical management of abdominal pain in the multiple myeloma patient

2011-07-26

Abstract: Background: The purpose of this retrospective study was to characterize the presentation, treatment, and outcomes of patients with multiple myeloma requiring surgical evaluation for abdominal pain. Methods: Medical records of patients with myeloma and abdominal pain evaluated by surgery over a period of 18 months were examined. Results: Twenty-one patients underwent surgical evaluation, with 23 diagnoses. Neutropenic enterocolitis (n = 5 [22%]) and ileus (n = 4 [17%]) were common diagnoses. Eleven patients (52%) were neutropenic. Peritonitis was noted in only 1 patient. Eastern Cooperative Oncology Group performance status was either 3 or 4 in most patients (67%). Surgery was performed in 5 patients. The 90-day mortality rate for all patients was 43%, with all deaths secondary to sepsis in patients managed without surgery. Conclusions: Patients with myeloma requiring surgical evaluation for abdominal pain have a unique differential diagnosis, with notable findings at presentation including the presence of cytopenia, lack of peritoneal signs, and low performance status.

Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy

2011-08-08

Abstract: Background: Neoadjuvant treatment frequently is performed in unresectable/borderline resectable pancreatic cancer. The aim of this study was to retrospectively compare postoperative outcomes and survival of patients who underwent pancreatectomy after neoadjuvant treatment for locally advanced/borderline resectable pancreatic cancer (neoadjuvant treatment group) with those of patients with resectable disease who underwent upfront surgery. Methods: Between 2000 and 2008, there were 403 patients who underwent pancreatic cancer resection, 41 (10.1%) patients after neoadjuvant treatment for initially unresectable tumors and 362 (89.9%) patients had upfront surgery. Univariate and multivariable analyses were performed. Results: Mortality/morbidity rates were similar in the 2 groups. Nodal metastases were significantly lower in the neoadjuvant treatment group (31.7% vs 86.2%; P < .001). A complete pathologic response was observed in 13.6% after neoadjuvant treatment. Median disease-specific survival from resection was 35 and 27 months in the neoadjuvant treatment and upfront groups, respectively (P = .74). In the neoadjuvant treatment group survival rates were similar in N0/N1 patients. Conclusions: Postoperative mortality and morbidity do not significantly increase after neoadjuvant treatment. Neoadjuvant treatment in locally advanced pancreatic cancer can lead to an objective pathologic response, but this does not significantly improve survival after resection.

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

Erik Dunki-Jacobs, Kevin Grannan, Sarah McDonough, Amy M. Engel — 2011-05-20

Abstract: Background: The purpose of this study was to describe the incidence and clinical/pathologic characteristics of papillary thyroid microcarcinoma (PMC) in a community hospital setting and to evaluate the frequency and characteristics of these lesions when unsuspected preoperatively. Methods: A total of 723 patients underwent a partial or total thyroidectomy. A retrospective review was performed. Results: A total of 194 of the 723 patients had a final diagnosis of papillary carcinoma. Ninety-six (49%) of these tumors were PMCs defined as being 1.0 cm or less in diameter. One third (32 of 96) of these lesions were multifocal and 16.7% (16 of 96) were found to have regional lymph node metastases. The majority (58%) of PMCs were found on final pathology and were clinically unsuspected (occult). Multifocality was found in 32.1% (18 of 56) of patients with clinically unsuspected PMC, with nodal metastases in 3.6% (2 of 56). The other 40 patients with PMC had surgeries performed for a clinical reason related to that pathologic lesion. This clinically suspected group was comparably multifocal (35%), but more likely to have cervical lymph node metastasis (35%). Sixty-six percent (37 of 56) diagnosed with a clinically unsuspected PMC underwent a partial thyroidectomy at the initial surgery. Conclusions: The prevalence of clinically unsuspected PMC in our population undergoing thyroidectomy was 7.7% (56 of 723). In our institution, this is more than half of all PMCs. The incidence of cervical lymph node metastasis in clinically unsuspected PMC was only 3.6% compared with 35% in clinically suspected disease, suggesting that the biological behavior (and possibly treatment) may be different. Long-term follow-up evaluation is needed to better evaluate the significance of these differences.

Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy

Kaori Ito, Hiromichi Ito, Edward E. Whang, Ali Tavakkolizadeh — 2011-07-26

Abstract: Background: In pregnant women, a high negative appendectomy (NA) rate often is reported; however, the outcome of pregnancy after a NA is not well studied. Methods: Among 1,696 consecutive patients (728 men and 968 women) who underwent an appendectomy at our institution (1996–2005), 87 pregnant women were identified. Postoperative surgical and obstetric outcomes were analyzed based on the final pathologic report of the appendix (normal appendix, inflamed, or perforated). Results: The NA rate was significantly higher in pregnant women compared with nonpregnant women (36% vs 14%; P < .05). The fetal demise rate was similar between the NA group and the inflamed group (3% vs 2%; P = NS), and highest (14%) in the perforated group, although this difference did not reach statistical significance (P = .3). Wound infections were most frequent in the perforated group (P < .05). Conclusions: NA during pregnancy is not free of risk to the fetus. We recommend careful assessment to avoid unnecessary exploration when appendicitis is suspected in pregnant women.

A positive intramammary lymph node does not mandate a complete axillary node dissection

Ricardo Diaz, Amy C. Degnim, Judy C. Boughey, Aziza Nassar, James W. Jakub — 2011-07-26

Abstract: Background: We hypothesized that even in the face of a positive intramammary lymph node (IMLN) a negative axillary sentinel lymph node (SLN) reliably stages the axilla and complete axillary lymph node dissection (CALND) can be avoided. Methods: A literature search identified 386 publications that included IMLNs and SLN biopsies. Patients with a positive IMLN and negative axillary SLN who underwent a CALND were included. A review of our database was also performed. Results: Twenty-one cases in the literature met our criteria. A review of our database resulted in 2 additional cases. Twenty-three patients were identified who had a positive IMLN, negative axillary SLN biopsy, and underwent a CALND. In all cases, the CALND was negative. Conclusions: An axillary SLN biopsy accurately represents the disease status of the axilla in cases with a positive IMLN. CALND can be avoided in the setting of a positive IMLN and a negative axillary SLN biopsy.

Surgical management of radiation-induced angiosarcoma after breast conservation therapy

2011-06-10

Abstract: Background: Radiation-induced angiosarcoma (RA) is a well-recognized complication of breast conservation therapy (BCT). Methods: Over a 12-year period, 14 patients with a median age of 68 years were identified retrospectively. The median latency from BCT to onset of RA was 81 months. The incomplete excision rate (complete histologic margin taken to be > 10 mm) was 46%. There was a significant difference in the size of the cutaneous defect between the complete and incomplete excision groups (412 vs 592 cm2, respectively; P < .05), indicating more extensive disease in the latter group. Results: The tumor recurred locally in 12 patients (92%). The median time to local recurrence (LR) in patients with incomplete excision was 3 versus 23 months in patients who had a complete excision. The median survival time for patients who underwent complete versus incomplete excision was 42 and 6 months, respectively. Conclusions: RA is a challenging condition, with a prolonged latency period and variable clinical progression. Incomplete excision of RA is a surrogate marker of aggressive disease and is associated with rapid LR and poor survival.

Changing trend in surgical indication and management for Graves' disease

Jeremy Yip, Brian Hung-Hin Lang, Chung-Yau Lo — 2011-06-20

Abstract: Background: Although thyroidectomy for Graves' disease (GD) is well established, surgical indications remain less well defined. This study aimed to evaluate the changes in surgical indication, type of resection, and surgical outcomes at a single institution. Methods: A total of 346 patients who underwent thyroidectomy for GD were divided into 2 time periods: period 1 (1995–2001) and period 2 (2002–2008). Their surgical indication, type of resection, and surgical outcomes were compared. Results: Patients in the earlier period were significantly younger, suffered more previous relapses, and were on a longer duration of antithyroid drugs before surgery. Graves' ophthalmopathy and refusal for radioactive iodine were the indications that changed significantly between the 2 periods. Total/near-total thyroidectomy was performed more commonly and resulted in a higher temporary hypoparathyroidism rate in the latter period (P < .001). Conclusions: Over the study period, significant changes in surgical indication, type of resection, and surgical outcomes were noted. Graves' ophthalmopathy became one of the most common surgical indications. Total thyroidectomy became the preferred surgery but that resulted in a higher temporary hypoparathyroidism rate.

Multidrug donor preconditioning protects steatotic liver grafts against ischemia-reperfusion injury

2011-07-22

Abstract: Background: Graft dysfunction of steatotic livers (SL) still remains a major challenge in liver transplantation. Different mechanisms are thought to be involved in the impaired tolerance of SL to ischemia-reperfusion injury. Thus, different pharmacologic strategies may need to be combined to effectively protect SL and to reduce graft dysfunction after transplantation. Therefore, we analyzed the effectiveness of a multidrug donor preconditioning (MDDP) procedure to protect SL from cold ischemia-reperfusion injury. Methods: Liver steatosis was induced by a high-carbohydrate, fat-free diet. A total of 24 Sprague–Dawley rats were divided into 3 groups (n = 8 each), including a control group with nonsteatotic livers (Con), a vehicle-treated SL group (SL-Con), and a SL group undergoing MDDP (SL-MDDP), including pentoxyphylline, glycine, deferoxamine, N-acetylcysteine, erythropoietin, melatonin, and simvastatin. MDDP was applied before liver perfusion with 4°C histidine-tryptophan-ketoglutarate (HTK) solution and organ harvest. After 24 hours of cold storage in HTK, postischemic reperfusion was performed in an isolated liver reperfusion model using 37°C Krebs-Henseleit bicarbonate buffer. Results: After 60 minutes of reperfusion, SL showed a significant reduction of bile flow as well as a marked increase of liver enzyme levels and apoptotic cell death compared with Con. This was associated with an increased malondialdehyde formation, interleukin-1 production, and leukocytic tissue infiltration. MDDP completely abolished the inflammatory response and was capable of significantly reducing parenchymal dysfunction and injury. Conclusions: MDDP decreases SL injury after cold storage and reperfusion. The concept of MDDP as a simple and safe preoperative regime, thus may be of interest in clinical use, expanding the donor pool from marginal donors.

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

Sapna Nagar, Daryl Reid, Peter Czako, Graham Long, Charles Shanley — 2011-07-15

Abstract: Background: The aim of this study was to determine whether minimally invasive radioguided parathyroidectomy (MIRP) and intraoperative parathyroid hormone–guided parathyroidectomy (ioPTH) have equivalent intermediate-term outcomes in primary hyperparathyroidism (PHPT). Methods: A retrospective study of 244 patients who underwent parathyroidectomy for PHPT in a 25-month time period was conducted. Patients who either underwent MIRP- or ioPTH-guided parathyroidectomies were included. The primary outcome was persistent disease. Conversion to bilateral exploration, complications, and multigland disease (MGD) were secondary outcomes. Results: There was 1 MIRP patient and no ioPTH patients who had persistent disease. The ioPTH group had more conversions to a bilateral exploration (bilateral neck exploration [BNE]) (3.7% vs 13%, P = .024). In the MIRP group, no patients were found to have MGD. In the ioPTH group, 7 patients with double adenomas and 6 patients with MGD were found (0 vs 13, P = .0028). Conclusions: ioPTH facilitates successful minimally invasive parathyroidectomy (MIP) when compared with MIRP and provides cure rates similar to BNE.

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma

2011-06-17

Abstract: Background: Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. Methods: Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). Results: HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. Conclusions: Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

Endoscopic ultrasonography is useful for monitoring the tumor response of neoadjuvant chemoradiation therapy in esophageal squamous cell carcinoma

2011-06-17

Abstract: Background: Recently, neoadjuvant chemoradiation therapy (CRT) has been introduced for treatment of esophageal squamous cell carcinoma (ESCC). This study was performed to investigate the usefulness of endoscopic ultrasonography (EUS) in comparison with EUS findings before and after CRT, and histologic findings. Methods: There were 33 patients with potentially resectable ESCC who underwent neoadjuvant CRT. Preoperative EUS and histologic findings were compared. EUS criteria were established on the basis of low and high echoic regions. Resected specimens were examined by hematoxylin-eosin, azan, and cytokeratin immunohistochemical staining. Results: Azan and cytokeratin staining clearly delineated fibrous changes and residual tumor. Low echoic regions corresponded to residual tumor and high echoic spots corresponded to fibrosis. All 12 patients classified as grade 1 on EUS diagnosis had histologic grade 1 tumors. Nineteen of 21 cases that presented with high echo were grade 2 or 3. The prognosis according to EUS diagnosis was similar to the histologic effect. Conclusions: Preoperative EUS findings reflected the histologic effect after neoadjuvant CRT. EUS is a useful tool to assess the effect for CRT and to predict the prognosis in ESCC patients.

Prestorage leukoreduction abrogates the detrimental effect of aging on packed red cells transfused after trauma: a prospective cohort study

2011-09-19

Abstract: Background: The aim of this study was to prospectively duplicate previous retrospective findings showing that prestorage leukoreduction blunts the detrimental effect of aging on banked packed red blood cells transfused after injury. Methods: Over 19 months, trauma patients transfused with ≥4 U of packed red blood cells and surviving ≥24 hours were followed. The age of each unit was collected. Results: The cohort consisted of 153 patients. All models showed no association between advancing blood age and the likelihood of developing multiple-organ dysfunction syndrome or infections, regardless of whether the mean age of blood was analyzed as a continuous variable, as a percentage of blood received that was <14 days old, or as a dichotomized value >14 or <14 days old. Conclusions: This prospective study duplicates previous retrospective findings of an abrogation of the detrimental effects of advancing mean packed red blood cell age on outcomes after trauma by performing prestorage leukoreduction.

Adrenocorticotropic hormone and cortisol response to corticotropin releasing hormone in the critically ill—a novel assessment of the hypothalamic-pituitary-adrenal axis

2011-06-17

Abstract: Background: The pathophysiology of adrenal insufficiency, common in surgical intensive care units, has not been fully elucidated. Methods: Patients at risk (age > 55 years, in the surgical intensive care unit >1 week, baseline cortisol < 20 μg/dL) were enrolled. After measuring cortisol and adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH) was administered. ACTH and cortisol were measured over 120 minutes. Short and long cosyntropin stimulation tests determined adrenal function. Area under the curve (AUC) and mixed linear models were used to compare cortisol and ACTH responses. Patients were grouped according to survival and response to stimulation testing. Chi-square and t tests were performed, and P values < .05 were considered statistically significant. Results: Six of 25 patients responded poorly to cosyntropin, and 5 died compared with 3 after a normal response (P < .01). ACTH (AUC) and ACTH peak were increased in nonsurvivors after CRH administration. Cortisol peak and AUC were not different. Conclusions: ACTH responsiveness was increased in nonsurvivors and may predict mortality.

Peritoneal fluid: a potential mechanism of systemic neutrophil priming in experimental intra-abdominal sepsis

2011-06-17

Abstract: Background: Recent studies suggest that peritoneal fluid (PF) may be an important mediator of inflammation. The aim of this study was to test the hypothesis that PF may drive systemic inflammation in intra-abdominal sepsis by representing a priming agent for neutrophils. Methods: PF was collected 12 hours after the initiation of intra-abdominal sepsis in swine. Naive human neutrophils were primed with PF before treatment with N-formyl-Met-Leu-Phe or phorbol 12-myristate 13-acetate to elucidate receptor-dependent and receptor-independent mechanisms of neutrophil activation. Flow cytometry was used to quantify neutrophil surface adhesion marker expression of integrins and selectins and superoxide anion production. Additionally, proinflammatory cytokines were quantified in PF. Results: PF primed neutrophils via receptor-dependent and receptor-independent mechanisms. There were significant increases in the proinflammatory cytokines interleukin-6 and tumor necrosis factor–α in PF correlating with the development of intra-abdominal sepsis. Conclusions: PF represents a priming agent for naive polymorphonuclear cells in intra-abdominal sepsis. This may be secondary to increased levels of proinflammatory cytokines. Strategies to reduce the amount of PF may decrease the systemic inflammatory response by reducing a priming agent for neutrophils.

Surgical outcomes for gastric cancer of a single institute in southeast China

Yong-Bin Ding, Tian-Song Xia, Jin-Dao Wu, Guo-Yu Chen, Shui Wang, Jian-Guo Xia — 2011-08-02

Abstract: Background: In recent years, with social and economic development and lifestyle changes, the incidence of gastric cancer as well as the surgical results and prognoses of patients with gastric cancer have changed significantly in southeast China. Methods: A total of 1,451 patients were divided into 2 groups according to admission time periods. Trends in clinicopathologic characteristics and operative outcomes of these patients were analyzed retrospectively. Results: The numbers of old and young patients were significantly increased in period 2 compared with period 1. Tumors located in the proximal stomach increased from 20.26% to 36.83%. The incidence of early gastric cancer was significantly increased from period 1 to period 2. Lymph node metastasis was seen more prevalently in period 2 than in period 1. The rate of operation-related major complications decreased from 5.23% to 1.43%. Operative mortality was .49% in period 1 and .24% in period 2. The 5-year survival rate increased from 38.40% to 53.99%. Conclusions: Early diagnosis, standardized surgical treatment including pertinent lymph node dissection, and better perioperative care notably improve the outcomes of patients with gastric cancer.

Kindlin-2: a novel adhesion protein related to tumor invasion, lymph node metastasis, and patient outcome in gastric cancer

2011-11-07

Abstract: Background: Kindlin-2 has been confirmed as an essential element of bidirectional integrin signaling. In recent years, the relationship between Kindlin-2 expression and cancers has been a focus of interest. However, the relationship between Kindlin-2 expression in gastric cancer and tumor invasion, metastasis, and the outcome of patients have not been studied. Methods: Kindlin-2 expression at protein and RNA levels were detected by Western blot and real-time polymerase chain reaction in 40 pairs of gastric cancer samples. In addition, the correlations between Kindlin-2 expression and clinicopathologic factors as well as the prognosis of the patients were analyzed. Multivariate Cox regression was used to study the effect of Kindlin-2 expression on overall and progression-free survival. Results: We found that Kindlin-2 was up-regulated both at RNA (P = .027) and protein levels (P = .014) in gastric cancer tissues. Tumor samples with high Kindlin-2 expression (Kindlin-2/β-actin:tumor tissue/paraneoplastic tissue, ≥2) was observed in 55% of the patients. Moreover, Kindlin-2 expression had a significant positive correlation with tumor stromal invasion (P = .014), lymph node metastasis (P = .007), and TNM stage (P = .014). Patients with high Kindlin-2 expression had significantly poorer overall survival (P = .012) and progression-free survival (P = .012). High Kindlin-2 expression was an independent risk factor of progression-free survival (hazard ratio, 5.2; 95% confidence interval, 1.1–3.3; P = .032). Conclusions: Kindlin-2 may play an important role in the development of gastric cancer and it is a potential factor that could be used to evaluate the outcome of gastric cancer. Kindlin-2 may shed new light on evaluating the prognosis and targeted therapy of gastric cancer.

Current status of laparoscopic total mesorectal excision

Jayprakash Gopall, Xiong Fei Shen, Yong Cheng — 2012-02-01

Abstract: Background: Rectal cancer is a common malignancy with considerable mortality. This review outlines the current status of laparoscopic total mesorectal excision as a treatment option for rectal cancer and emphasizes the need for standardized approaches. Methods: We searched PubMed for the terms “total mesorectal excision,” “rectal cancer,” and “laparoscopic surgery” used in the literature between 1993 and 2010. Additional material regarding the latest statistics from the American Cancer Society, reports from the Cochrane Database of Systemic Reviews, and meta-analyses also were searched. Results: Ninety-six articles were selected: (1) 22 randomized controlled trials, (2) 25 nonrandomized comparative studies, (3) 31 case series, (4) 14 reviews, and (5) 1 report from the Cochrane Database of Systemic Reviews; 3 meta-analyses also were reviewed. Exclusion criteria included non-English language articles and case reports. Conclusions: At present, open resection is still the standard in rectal cancer and the role of laparoscopy is yet to be defined. The benefits of laparoscopic total mesorectal excision have been clearly translated in the surgical management of rectal cancer. Unfortunately, the lack of reports from larger prospective randomized studies have hindered its use so far.

Historical review of emergency tourniquet use to stop bleeding

2011-07-22

Abstract: Background: Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present. Methods: We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed. Results: The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet’s history and voice opinions based on anecdotal observations. Conclusions: Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.

Do not teach me while I am working!

Adam Dubrowski, Ryan Brydges, Lisa Satterthwaite, George Xeroulis, Roger Classen — 2012-02-01

Abstract: Background: The aim of this study was to determine if technical surgical experience enhances the learning of new cognitive information under multitasking conditions. Methods: Junior (years 1–3) and experienced (years 4 and 5) general surgery residents performed a Nissen fundoplication on a synthetic model (the primary task). While performing the primary task, they listened to and memorized information describing the steps of a computer-assisted hip replacement surgery (the secondary task). Performance on the primary and secondary tasks was assessed using performance metrics and multiple-choice questions. Results: The primary task was performed better by the senior than the junior trainees (P = .001, P = .007). The senior trainees also scored higher on the secondary task than the junior trainees (P = .001). Conclusions: Senior trainees have superior capacity to multitask. This may have direct implications on both clinical and simulation-based education, such that educators need to adjust the amount of information presented in accordance to trainees' levels of training.

The formal and informal surgical ethics curriculum: views of resident and staff surgeons in Toronto

Frazer Howard, Martin F. McKneally, Ross E.G. Upshur, Alex V. Levin — 2011-06-30

Abstract: Background: Understanding what staff surgeons think surgical trainees should learn and the ethical issues that trainees need to manage can strengthen surgical ethics education. Methods: Participants were recruited from the 15 surgical specialty and subspecialty programs at the University of Toronto. Semistructured interviews and focus groups were conducted with 13 ethics coordinators from the surgical staff and 64 resident trainees. Data were analyzed qualitatively using modified thematic analysis. Results: All coordinators and trainees felt that ethics education was an important component of surgical training. Real cases, varying teaching methods, and teachers with applicable clinical experience were valued. Trainees identified intraprofessional and interprofessional conflict, staff behavior perceived to be unethical, and their own lack of experience as challenging issues rarely addressed in the formal ethics curriculum. Conclusions: Ethics education is highly valued by trainees and teachers. Some ethical issues important to trainees are underrepresented in the formal curriculum. Staff surgeons and senior residents are practicing ethicists and role models whose impact on the moral development of residents is profound. Their participation in the formal curriculum helps less experienced junior residents realize its value.

Operating room introduction for the novice

2011-06-23

Abstract: Background: This study assessed the implementation of a theater induction curriculum through a didactic lecture, an online Second Life operating room, and a simulated operating suite. Methods: Sixty operating room novices were randomized into 4 groups: control (n = 15), didactic lecture (n = 15), Second Life (n = 15), and simulated operating suite (n = 15). The study followed a pretest and posttest design with a training intervention between operating room attendances. Outcome measures were knowledge, skills, and attitudes, measured using observed behavior and a self-report scale, with knowledge further assessed using multiple-choice questionnaires. Results: The lecture, Second Life, and simulated operating suite groups demonstrated significant improvements in all outcome measures. After the intervention, these 3 groups had significantly higher behavior (P < .001), self-report (P < .05), and knowledge (P < .05) scores than the control group. Conclusions: This study demonstrates the value of delivering a theater induction curriculum for operating room preparation.

2012-02-01

The American Journal of Surgery

Editorial Board

Carotid stenosis: change of treatment plan based on repeat duplex ultrasonography

The surgical management of abdominal pain in the multiple myeloma patient

Outcomes after resection of locally advanced or borderline resectable pancreatic cancer after neoadjuvant therapy

Clinically unsuspected papillary microcarcinomas of the thyroid: a common finding with favorable biology?

Appendectomy in pregnancy: evaluation of the risks of a negative appendectomy

A positive intramammary lymph node does not mandate a complete axillary node dissection

Surgical management of radiation-induced angiosarcoma after breast conservation therapy

Changing trend in surgical indication and management for Graves' disease

Multidrug donor preconditioning protects steatotic liver grafts against ischemia-reperfusion injury

Outcomes analysis of intraoperative adjuncts during minimally invasive parathyroidectomy for primary hyperparathyroidism

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma

Endoscopic ultrasonography is useful for monitoring the tumor response of neoadjuvant chemoradiation therapy in esophageal squamous cell carcinoma

Prestorage leukoreduction abrogates the detrimental effect of aging on packed red cells transfused after trauma: a prospective cohort study

Adrenocorticotropic hormone and cortisol response to corticotropin releasing hormone in the critically ill—a novel assessment of the hypothalamic-pituitary-adrenal axis

Peritoneal fluid: a potential mechanism of systemic neutrophil priming in experimental intra-abdominal sepsis

Surgical outcomes for gastric cancer of a single institute in southeast China

Kindlin-2: a novel adhesion protein related to tumor invasion, lymph node metastasis, and patient outcome in gastric cancer

Current status of laparoscopic total mesorectal excision

Historical review of emergency tourniquet use to stop bleeding

Do not teach me while I am working!

The formal and informal surgical ethics curriculum: views of resident and staff surgeons in Toronto

Operating room introduction for the novice

Table of contents