Surgery Commons^™

Operating Room First Start Efficiency Throughout A Large Urban Hospital System, Callie Cox Bauer, Kiley A. Bernhard, Danielle M. Greer, Scott Kamelle

Journal of Patient-Centered Research and Reviews

Background: Operating room delays decrease health care system efficiency and increase hospital costs. Data on delays in a multihospital system are sparse.

Purpose: In an effort to improve our operating room efficiency, we investigated operating room delays, the causes and the impending financial impact.

Methods: A retrospective analysis on first case-of-the-day surgeries at three hospitals during 2013 was conducted. Delays were defined as in-room time being after scheduled surgery start time. Length of delay and causes were recorded. Patient demographics, body mass index, hospital facility, total number of procedures, provider specialty and time of patient arrival were incorporated into a …

Randomized Clinical Trial Comparing Perioperative Care For Breast Cancer Patients At A Patient Hotel Versus A General Surgical Ward, Madleen Anna Camilla Huzell, Johan Frisack, Kristina Dalberg

Patient Experience Journal

Breast cancer is the most frequent cancer among women in Europe and the US. The aim of this study was to assess whether perioperative care, for breast cancer patients, provided at a patient hotel could be an alternative to the conventional care in an ordinary surgical ward. The study focuses solely on the patients’ experience of the provided care with a primary outcome that perioperative care at the patient hotel would be valued better than care in a general ward. Prospective, randomized single centre study. Between 2010 and 2012 a total of 151 patients < 80 years and without severe comorbidities were included in the trial, whereof 76 patients were randomised to the ward group and 75 patients to the hotel group. Five patients were excluded from each group. The validated IN2005-E questionnaire was used to evaluate the patients’ experiences of the care. The response rate was high with 65 patients answering the IN2005-E in each group. No difference could be found between the two groups regarding patient characteristics, type of surgery or tumour characteristics. The patients generally perceived the quality of the provided care as high. However, in the hotel group there was a better experience of care regarding issues such as coordination, privacy, some aspects of medical information, availability and the courtesy of the nurses. For selected patients, perioperative care at a patient hotel is an appreciated alternative to care at a surgical ward.

When Operating On Dead People Saves Lives: Benefits Of Surgical Organ Donor Intensivists, Kristin Long, Cynthia Talley, Rebecca B. Yarrison, Andrew Bernard

Surgery Faculty Publications

Solid organ transplantation has emerged as a life-saving treatment for many patients suffering from end-stage organ failure. Organs have been successfully recovered after a variety of aggressive interventions. We propose that decompressive laparotomy, when clinically indicated, should be considered in the aggressive resuscitation of potential organ donors. A thorough literature review examining aggressive interventions on potential organ donors was conducted after experience with a unique case at this institution. Articles were reviewed for the types of interventions performed as well as the time frame in relation to organ donation. In our case, several ethical issues were raised when considering decompressive …

Trends In Initial Management Of Prostate Cancer In New Hampshire, Johann Ingimarsson, Maria Celaya, Michael Laviolette, Judy R. Rees, Elias Hyams

Dartmouth Scholarship

Purpose Prostate cancer management strategies are evolving with increased understanding of the disease. Specifically, there is emerging evidence that ‘‘low-risk’’ cancer is best treated with observation, while localized ‘‘high-risk’’ cancer requires aggressive curative therapy. In this study, we evaluated trends in management of prostate cancer in New Hampshire to determine adherence to evidence- based practice. Methods From the New Hampshire State Cancer Registry, cases of clinically localized prostate cancer diagnosed in 2004–2011 were identified and classified according to D’Amico criteria. Initial treatment modality was recorded as surgery, radiation therapy, expectant management, or hormone therapy. Temporal trends were assessed by Chi-square …

Role Of Surgery In Locally Advanced Prostate Cancer, Nazim Syed Muhammad, Farhat Abbas

Section of Urology

A significant proportion of patients present with locally advanced prostate cancer with inherent higher risk of local recurrence and systemic relapse after initial treatment. Recent literature favors combination of radiation therapy and extended hormonal therapy for this subset of patients. The effectiveness of Radical prostatectomy (RP) alone for locally advanced prostate cancer is controversial and is a focus of debate. However, it can decrease the tumor burden and allows the accurate and precise pathological staging with the need for subsequent treatment. Comparison of RP and other treatment modalities is difficult and incorrect because of inherent selection bias. RP as a …

A Feasibility Pilot Study On The Use Of Complementary Therapies Delivered Via Mobile Technologies On Icelandic Surgical Patients' Reports Of Anxiety, Pain, And Self-Efficacy In Healing, Margaret M. Hansen Edd, Msn, Rn

Nursing and Health Professions Faculty Research and Publications

Background Complementary therapies (CT), such as relaxation technique, massage, guided imagery, and accupuncture have shown to benefit patients undergoing surgery. The aim of this study was to determine the feasibility of using audio relaxation technique (ART), music intervention (MI), nature video application with music (NVAM), and nature video application without music (NVA) delivered via mobile technologies in a clinical setting. Secondary, the effects of ART, MI, NVAM and NVA on patients’ state anxiety, pain perception, and perceived self-efficacy in healing were determined. Methods A randomized clinical trial (RCT) involving 105 same day surgery (SDS) patients, who were assigned to an …

Iroa: The International Register Of Open Abdomen., Frederico Coccolini, Fausto Catena, Giulia Montori, Marco Ceresoli, Roberto Manfredi, Gabriela Elisa Nita, Ernest E. Moore, Walter Biffl, Rao Ivatury, James Whelan, Gustavo Fraga, Ari Leppaniemi, Massimo Sartelli, Salomone Di Saverio, Luca Ansaloni

Surgery Publications

Actually the most common indications for Open Abdomen (OA) are trauma, abdominal sepsis, severe acute pancreatitis and more in general all those situations in which an intra-abdominal hypertension condition is present, in order to prevent the development of an abdominal compartment syndrome. The mortality and morbidity rate in patients undergone to OA procedures is still high. At present many studies have been published about the OA management and the progresses in survival rate of critically ill trauma and septic surgical patients. However several issues are still unclear and need more extensive studies. The definitions of indications, applications and methods to …

A Comparison Of Angiography Versus Intravascular Ultrasound In The Treatment Of Peripheral Arterial Disease, Michael Pompliano

Senior Theses

Peripheral Arterial Disease is a growing epidemic throughout the United States. It is estimated that 8 to 12 million Americans currently suffer from PAD, a disease of the circulatory system that limits blood flow to your hands and feet. This limited blood flow is due to the narrowing of the arteries that supply blood throughout your body and can disrupt the balance of the nerves and tissues that make up your extremities. If left untreated, it can cause irreparable, life- threatening damage that may result in amputation of the diseased limb. Although the mechanism of PAD is known and well …

"What Happens In Romania..." Comes Back To The United States And Becomes A Quilt, Ashley Ehlers, Kaitlyn Torres

Senior Theses

Our senior thesis project is a quilt that chronicles our experiences on the Maymester trip to Romania through the Honors College, during which we were able to shadow surgeons in the Oncology Hospital and General Surgery III Hospital in Cluj-Napoca. In our quilt, we included some of the most common surgeries we saw while shadowing Romanian doctors: breast removal, gall bladder removal, appendix removal, removal of a section of the large intestine, and removal of the uterus. The final product of this quilt shows every level of the abdominal muscles and organs from the anterior skin to the kidneys.

To …

Is Surgical Spinal Decompression For Supratentorial Gbm Symptomatic Drop Down Metastasis Warranted? A Case Report And Review Of Literature, Muhammad Babar Khan, Muhammad Riaz, Muhammad Ehsan Bari

Medical College Documents

Background: Symptomatic spinal metastasis from an intracranial primary
glioblastoma multiforme (GBM) is very rare. Our literature search identified a total
of 42 such patients of which 11 were treated with surgical decompression for spinal metastasis with only one such report from the pediatric age group. Previous studies have reported variable outcomes after surgical management.

Case Description: We report the case of a 16‑year‑old boy who underwent
surgical spinal decompression for spinal metastasis after intracranial GBM. The
patient regained motor and autonomic function following surgery and reported
improvement in pain. We also present findings from a literature review using …

Survival After Pneumonectomy For Stage Iii Non-Small Cell Lung Cancer, Sibu P. Saha, Rohan J. Kalathiya, Daniel L. Davenport, Victor A. Ferraris, Timothy W. Mullett, Joseph B. Zwischenberger

Surgery Faculty Publications

OBJECTIVES: Stage III non-small cell lung cancer (NSCLC) has a poor prognosis. Reports suggest that five-year survival after current treatment is between 14 to 24 percent. The purpose of this retrospective study was to investigate the morbidity and mortality of patients diagnosed with stage III NSCLC and treated with pneumonectomy at the University of Kentucky Medical Center in Lexington, KY.

METHODS: We reviewed the medical record and tumor registry follow-up data on 100 consecutive patients who underwent pneumonectomy for lung cancer at the University of Kentucky.

RESULTS: We identified thirty-six patients in stage III who underwent pneumonectomy. Ten patients had …

Patient Safety In The Cardiac Operating Room: Human Factors And Teamwork: A Scientific Study From The American Heart Association, Joyce A. Wahr, Richard L. Prager, J. H. Abernathy Iii, Elizabeth A. Martinez, Eduardo Salas, Patricia C. Seifert, Robert C. Groom, Bruce D. Spiess, Bruce E. Searles, Thoralf M. Sundt Iii, Juan A. Sanchez, Scott A. Shappell, Michael H. Culig, Elizabeth H. Lazzara, David C. Fitzgerald, Vinod H. Thourani, Pirooz Eghtesady, John S. Ikonomidis, Michael R. England, Frank W. Selke, Nancy A. Nussmeier

Publications

The cardiac surgical operating room (OR) is a complex environment in which highly trained subspecialists interact with each other using sophisticated equipment to care for patients with severe cardiac disease and significant comorbidities. Thousands of patient lives have been saved or significantly improved with the advent of modern cardiac surgery. Indeed, both mortality and morbidity for coronary artery bypass surgery have decreased during the past decade. Nonetheless, the highly skilled and dedicated personnel in cardiac ORs are human and will make errors. Refined techniques, advanced technologies, and enhanced coordination of care have led to significant improvements in cardiac surgery outcomes.

State-By-State Variation In Emergency Versus Elective Colon Resections: Room For Improvement., Augustine C. Obirieze, Mehreen Kisat, Caitlin W. Hicks, Tolulope A. Oyetunji, Eric B. Schneider, Darrell J. Gaskin, Elliott R. Haut, David T. Efron, Edward E. Cornwell, Adil H. Haider

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: Compared with elective surgical procedures, emergency procedures are associated with higher cost, morbidity, and mortality. This study seeks to investigate potential state-by-state variations in the incidence of emergent versus elective colon resections.

METHODS: A retrospective analysis of all adult patients (aged ≥18 years) included in the Nationwide Inpatient Sample from 2005 to 2009 who underwent hemicolectomy (right or left) or sigmoidectomy was conducted. Discharge-level weights were applied, and generalized linear models were used to assess the odds of a patient undergoing emergent versus elective colon surgery nationally and for each state after adjusting for patient and hospital factors. Odds …

A Case Of Congenital Unilateral Absence Of The Vas Deferens, Bi Mo, Vishnu Garla, Lawrence M. Wyner M.D.

Surgery

Background

Congenital unilateral absence of the vas deferens occurs in 0.5%–1.0% of males. It has been associated with various genitourinary abnormalities, including renal agenesis. We report a case of congenital unilateral absence of the vas deferens found incidentally during vasectomy in a patient with known unilateral renal agenesis.

Case presentation

A 24-year-old male presented to our urology clinic requesting vasectomy. His past history was significant for left renal agenesis. Following successful right vasectomy, several attempts to locate the left vas deferens were unsuccessful. We diagnosed congenital unilateral absence of the vas deferens. Follow-up semen analysis showed azoospermia.

Conclusion

As vasectomies …

Extracorporeal Membranous Oxygenation Mimics Aortic Dissection On Cat Scan., Philip Batista, Nicholas C. Cavarocchi, Hitoshi Hirose

Department of Surgery Faculty Papers

A 66 year-old female presented with refractory acute congestive heart failure, cardiogenic shock, and ventricular tachyarrhythmia. Veno-arterial extracorporeal membrane oxygenation (ECMO) was placed via femoral cannulation for salvage and stabilized. CAT scan of the chest performed as a part of heart transplant work-up, demonstrated an unequal distribution of intravenous contrast in the aortic arch (Figure 1). Radiologist’s preliminary reading was of “aortic dissection” while in fact this is truly “normal ECMO flow”.

Open Versus Laparoscopic Hiatal Hernia Repair., Terrence M. Fullum, Tolulope A. Oyetunji, Gezzer Ortega, Daniel D. Tran, Ian M. Woods, Olusola Obayomi-Davies, Orighomisan Pessu, Stephanie R. Downing, Edward E. Cornwell

Manuscripts, Articles, Book Chapters and Other Papers

BACKGROUND: The literature reports the efficacy of the laparoscopic approach to paraesophageal hiatal hernia repair. However, its adoption as the preferred surgical approach and the risks associated with paraesophageal hiatal hernia repair have not been reviewed in a large database.

METHOD: The Nationwide Inpatient Sample dataset was queried from 1998 to 2005 for patients who underwent repair of a complicated (the entire stomach moves into the chest cavity) versus uncomplicated (only the upper part of the stomach protrudes into the chest) paraesophageal hiatal hernia via the laparoscopic, open abdominal, or open thoracic approach. A multivariate analysis was performed controlling for …

Successful Management Of Severe Liver Failure On Venoarterial Extracorporeal Membrane Oxygenation Using Molecular Adsorbent Recirculating Systeme., Shigeki Tabata, Nicholas Cavarocchi, Hitoshi Hirose

Department of Surgery Faculty Papers

A 49-year-old female with Adriamycin induced cardiomyopathy presented with decompensated biventricular congestive heart failure. Despite multiple Inotropes, the patient’s hemodynamics deteriorated and she underwent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) placement as a bridge to decision. Pre-ECMO workup showed liver dysfunction with elevated total bilirubin of 5.9 mg/dl, normal liver enzymes and liver ultrasound image. Tentative diagnosis of “end-stage liver failure” was made without a biopsy.

Shortly after initiation of ECMO, the patient developed massive hemoptysis which was successfully managed with continuation of ECMO and ventilator management. [i] The patient’s total bilirubin continued to increase to peak of 56 mg/dl on …

Quantitative, Spectrally-Resolved Intraoperative Fluorescence Imaging, Pablo A. Valdés, Frederic Leblond, Valerie L. Jacobs, Brian C. Wilson, Keith D. Paulsen, David W. Roberts

Dartmouth Scholarship

Intraoperative visual fluorescence imaging (vFI) has emerged as a promising aid to surgical guidance, but does not fully exploit the potential of the fluorescent agents that are currently available. Here, we introduce a quantitative fluorescence imaging (qFI) approach that converts spectrally-resolved data into images of absolute fluorophore concentration pixel-by-pixel across the surgical field of view (FOV). The resulting estimates are linear, accurate, and precise relative to true values, and spectral decomposition of multiple fluorophores is also achieved. Experiments with protoporphyrin IX in a glioma rodent model demonstrate in vivo quantitative and spectrally-resolved fluorescence imaging of infiltrating tumor margins for the …

Successful Management Of Bleeding Complications In Patients Supported With Extracorporeal Membrane Oxygenation With Primary Respiratory Failure., K Lamb, Sw Cowan, N Evans, H Pitcher, T Moritz, M Lazar, H Hirose, Nc Cavarocchi

Department of Cancer Biology Faculty Papers

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a lifesaving procedure in patients with severe respiratory insufficiency failing conventional support. Bleeding complications are common due to the necessity for anticoagulation and circuit-related factors. METHODS: A retrospective review was conducted in patients requiring ECMO for respiratory failure from 7/2010 to 6/2011 to identify episodes of major bleeding, bleeding management and outcomes. RESULTS: Twenty-one patients were supported with ECMO during the study although five experienced massive bleeding related to chest tube insertion, jejunal arterio-venous malformations, distal perfusion cannula dislodgement and ventricular rupture. Patients required aggressive resuscitation or endoscopic or operative intervention, totaling 28 procedures. …

Parenthood With Exposure To Mycophenolic Acid Products, Sophia M. Termimi, Megan Clary, Lisa Coscia, Carolyn Mcgrory, Vincent T. Armenti

Department of Surgery Faculty Papers

Successful pregnancy outcomes have been reported in all solid-organ transplant recipients on a variety of immunosuppressive medication regimes. In October 2007, the FDA pregnancy category of mycophenolic acid products (MPA) was changed from category C to D, based on registry and post-marketing data which revealed a higher incidence of spontaneous abortions and structural birth defects. The purpose of this abstract is to describe pregnancy outcomes with exposure to MPA and pregnancies fathered by male transplant recipients conceived while taking MPA. Data were collected by the National Transportation Pregnancy Registry (NTPR) via questionnaires, telephone interview and medical records. There were 152 …

Analysis Of Bar Deformation Under Sternum Forces During Surgical Correction Of Pectus Excavatum In Children, Rohit N. Nikam

Mechanical & Aerospace Engineering Theses & Dissertations

Pectus excavatum (PE) also known as sunken or funnel chest is the most common chest wall deformity and affects 1 in every 1,000 children. In PE patients, the middle lower portion of the sternum is depressed producing concave appearance of the anterior part of the chest wall. This problem can be corrected with minimally invasive surgery developed by Dr. Donald Nuss in 1986. A specially made steel bar is implanted to lift the sternum to its normal position. This technique has been modified several times to improve safety and effectiveness of the bar placement and removal. One of the significant …

She’S A Survivor: Post-Operative Counseling And Its Importance To The Recovery Of A Woman Victimized By Female Genital Mutilation, Jacent Wamala

McNair Poster Presentations

The prevalence of Female Genital Mutilation and the difficulty in preventing its practice call for a fresh way of resolving the problem. As the availability of medical professionals equipped with the ability to correct clitoral mutilation grows, there is also an increasing need for professionals that can help the victims after the reconstructive surgery. Post-operative therapy for victims that have opted to receive reconstructive surgery is necessary in order to fully recover. Furthermore, more research in this area is needed to support the findings of this review and will fill the physical and emotional gap exhibited in prior studies related …

Principles Of Combat Surgical Care In A Staged Evacuation System, Vivian Mcalister, Rob Stiegelmar, Brian Church, Ray Kao

Data and Test Instruments

Background: The NATO hospital classification of hospitals describes an orderly transfer of patients with severe injuries through a series of increasingly sophisticated hospitals as they are brought from the point of injury to their home hospital. Forward hospital surgery is restricted to damage control and resuscitation while definitive surgery is performed at home by the destination surgical team. In reality many patients enter the hospital chain higher up and some receive definitive surgery as they proceed through the chain of evacuation. The purpose of this paper is to determine if clear doctrine exists to guide the performance of surgery on …

The Role Of Surgery In Building Resilience To Blast Attacks, Vivian Mcalister

Data and Test Instruments

Blast attacks are the commonest form of terrorist attack on civilians. Blast often causes injury from industrial accidents. Blast injury is the most common cause of injury and death in modern combat. A recent review of Canadian fatal casualties in Afghanistan found 81% to have been caused by blast, almost four times the number killed by gun shot wounds. Improvised explosive devices (IED) caused 78% of the blasts with another 20% being due to rocket propelled grenades (RPG).1 The purpose of this review is to outline the mechanisms of injury, to define the surgical response and to understand the implications …

Evaluation Of The Use Of Patient-Focused Simulation For Student Assessment In A Surgery Clerkship., Gerald A Isenberg, Katherine W Berg, Judith A Veloski, Dale D Berg, J J. Veloski, Charles Yeo

Department of Surgery Faculty Papers

BACKGROUND: The purpose of this study was to evaluate the use of simulated patients in conjunction with anatomic and tissue task-training models to assess skills.

METHODS: Faculty reviewed the objectives of the clerkship to identify skills to be acquired. Three cases were developed related to rectal examination, suturing, and inserting intravenous lines and nasogastric tubes. Student scores were based on their ability to gather data from simulated patients and perform procedures on simulation models.

RESULTS: A total of 670 students were assessed between 2006 and 2009. Alpha reliability coefficients were .97 for Communication/Interpersonal Skills, .71 for Procedures, and .58 for …

Thomas Dent Mütter: The Humble Narrative Of A Surgeon, Teacher, And Curious Collector., Jennifer A. Baker, B.S., Charles J. Yeo, Md, Pinckney J. Maxwell, Iv, Md

Department of Surgery Gibbon Society Historical Profiles

Thomas Dent Mutter, a beloved teacher, respected colleague, devoted husband, surgical pioneer, and legendary collector, emerged from a tragic childhood as an ambitious young physician who would leave a permanent imprint on medical education (Fig. 1). Dr. Mutter is best known in the Philadelphia area for the museum of medical curiosities, which bears his name. Overflowing with various medical memorabilia, anatomical and pathological specimens, casts, models, watercolors, and historical instruments, the Mutter Museum often overshadows the numerous other contributions Dr. Mutter made during his shortened life.1 A quote from Henry Brooks Adams is quite apropos, ‘‘A teacher affects eternity; he …

Safety And Tolerability Of An Ovine-Derived Polyclonal Anti-Tnfα Fab Fragment (Azd9773) In Patients With Severe Sepsis, Peter E. Morris, Brian Zeno, Andrew C. Bernard, Xiangning Huang, Steven G. Simonson, Gordon R. Bernard

Surgery Presentations

Sepsis remains a significant medical problem. TNFα is a central cytokine in sepsis pathophysiology. We conducted a phase IIa trial in patients with severe sepsis to assess the safety and tolerability of an intravenously infused ovine-derived polyclonal anti-TNFα Fab fragment (AZD9773).

Ercc1 And Rrm1 As Predictors Of Survival And Response In Pancreatic Ductal Adenocarcinoma Treated With Gemcitabine-Based Chemotherapy, Thomas Holdbrook, Kathleen D. Danenberg, Suneeta Satti, Jessica Kline, Charles J. Yeo, Jonathan R. Brody, Peter Mccue, Agnieszka K. Witkiewicz

Department of Surgery Faculty Papers

Conclusion:

In this study, we used RT-PCR and IHC to analyze RRM1 and ERCC1 mRNA and protein expression in PDA specimens. PDA patients with low expression of RRM1 by IHC derived benefit from gemcitabine-based chemotherapy. Assessment of RRM1 mRNA expression was limited by the small sample size. Low ERCC1 expression by RT-PCR was associated with a 2.5 times higher risk of mortality than high expression (p=0.031). There was no association between ERCC1 expression by IHC and survival; however, agreement between mRNA and protein expression was poor for ERCC1. This study demonstrates the ERCC1 and RRM1 expression have an impact on …

Composite Tissue Allotransplantation To Treat Veterans With Complex Amputation Injuries, Vivian Mcalister, Ray Kao, Brian Church, Markus Besemann, Rob Stiegelmar

Data and Test Instruments

Amputee rehabilitation may be limited by complexity of injury (e.g. bilateral arm amputation), associated injury (e.g. colostomy) or by the level of amputation (e.g. high above knee). Our objective is to assess the potential for composite tissue allotransplantation (CTA) to overcome these barriers. Medical literature was searched and programs were surveyed regarding the current status of CTA. Results CTA remains an experimental reconstructive option that involves a large collaborative (physiatry, orthopaedic, plastic and transplant surgeons). Limb transplantation has evolved out of limb reimplantation surgery and organ transplantation. Approximately 10 programs world wide, with almost a decade of experience, report 90% …

Systematic Review Of Home Physiotherapy After Hip Fracture Surgery, Saurabh Mehta, Jean-Sébastien Roy

Physical Therapy Faculty Research

OBJECTIVE: To compare the benefits of home physiotherapy, institution-based physiotherapy and no physiotherapy following hip fracture surgery.

DESIGN: Systematic review and meta-analysis of randomized controlled trials.

METHODS: Two reviewers independently extracted data from 5 included studies. Standardized mean differences were pooled for health-related quality of life and performance-based outcomes. Review Manager Version 5 was used for data analysis.

RESULTS: Analysis of the 5 included studies indicated that home physiotherapy was better than no physiotherapy and similar to outpatient physiotherapy in improving patient-reported health-related quality of life. Performance-based outcomes were marginally better following outpatient physiotherapy compared with home physiotherapy 3 and …