SurgeXperiences 1.03

Welcome to the third edition of SurgeXperiences, the first carnival of surgery. I’m honored to bring you this surgical carnival.

This will be a practical and concise edition. The objective of blogs (in my point of view) is to answer questions as quickly as possible, so lets start with the HOW-TOs. Enjoy.

Thank you for your time and participation. Make sure you read the next edition of SurgExperiences, created by Jeff Leow

Mexican scientific work is Worldwide recognized

The British journal The Lancet chose as Paper of the Year an investigation published in January 2006 by Guillermo Ruiz-Palacios y Santos about rotavirus vaccine.

This study, included 63,225 breastfeeded infants and was first published by the New England Journal of Medicine.

With their conclusions, the Mexican government will change the National Vaccination Scheme, and now will include rotavirus vaccine.

Congratulations to Dr. Ruiz-Palacios and all the crew of the Human Rotavirus Vaccine Study Group.

Older surgeons have higher mortality rates

Like those nice posts of Kidney Notes called Hilarious Journal Articles I have read in the September issue of Annals of Surgery an article wich concludes the following:

For some complex procedures, surgeons older than 60 years, particularly those with low procedure volumes, have higher operative mortality rates than their younger counterparts. For most procedures, however, surgeon age is not an important predictor of operative risk.

In this study, it was used the national Medicare files examining operative mortality in 461,000 procedures. There were three groups of surgeons age 40 years and less, 41 to 50 years, 51 to 60 years, and 61 years and more.

The complex procedures were: esophagectomy, cystectomy, lung resection, aortic valve replacement and aortic aneurysm repair.

Less experienced surgeons (those of 40 years and less) had comparable mortality rates to surgeons aged 41 to 50 years for all procedures. So, why everyone call them unexperienced?

Mobile Data Visualization

At Quinn Lab, San Diego Supercomputer Center, doctor Quinn, has an outstanding project called Patient Notes with mobile devices.

The famous and enthusiastic project of Dr. Quinn and Dr. Wright, consists in the transmission of medical data to mobile devices such as PDAs and cell phones to enable medical workers in the field to instantaneously gain access to, view and prognosticate on complex medical visualizations.

With this software, medical notes and patient tests can be downloaded onto a cell phone or PDA in just minutes.

All the data on a phone is stored in the memory expansion slot. In these medical phones, however, Instead of music and digital pictures, it could hold a virtual scan of the body and much more.


Dr. Quinn's Patient Notes
The 3-D mobile medical data program should be available within a year.

This is a good start to revolutionize the way of getting access to medical information about our patients.
Its uses are endless: ambulance, emergency departments, office, etc.

Laparoscopic vs Conventional Nissen fundoplication

From Annals of Surgery

A randomized trial that compares (subjectively and objectively) the laparoscopic versus conventional Nissen fundoplication in 5 years.

The comparision was made with 148 (79 laparoscopic vs 69 patients who were requested to fill in a questionnarie and to undergo esophageal manometry and 24 hours pH-metry.

Results: At 5 years follow-up, 20 patients had undergone reoperation: 12 after laparoscopy (15%) and 8 after conventional (12%). There was no difference in subjective outcome, with overall satisfaction rates of 88% (lap) and 90% (conv). Total esophageal acid exposure times (pH < 4) were 2.1% +/- 0.5% and 2.0% +/- 0.6%, respectively (P = 0.21). Antisecretory medication was taken daily in 14% and 16%, respectively (P = 0.29). There was no correlation between medication use and acid exposure and indices of symptom-reflux association. No significant differences between subjective and objective results at 3 to 6 months and results obtained at 5 years after surgery were found.

It concludes that the effects of laparoscopic and conventional are sustained up to 5 years and the long-term results are comparable. A substantial minority of patients in both groups had a second antireflux operation or took antisecretory drugs, although the use of those medications did not appear to be related to abnormal esophageal acid exposure.

I think laparoscopic approach is clearly superior due to the recuded hospital days and short convalescence period.
Dr. Jon Mikel Iñarritu

Migraine in women is linked with cardiovascular disease

Via JAMA. 2006;296:283-291.

Migraine with aura is associated with increased risk of major cardiovascular disease (CVD), myocardial infarction, ischemic stroke, and death due to ischemic CVD, coronary revascularization and angina. Active migraine without aura was not associated with increased risk of any CVD event.

This prospective cohort-type study enrolled 27,840 women aged 45 years or older who were participating in the Women’s Health Study, were free of CVD and angina at study entry (1992-1995), and who had information on self-reported migraine and aura status, and lipid measurements. This report is based on follow-up data through March 2004.

At baseline, 5125 women (18.4%) reported any history of migraine; of the 3610 with active migraine (migraine in the prior year), 1434 (39.7%) indicated aura symptoms.

During a mean of 10 years of follow-up, 580 major CVD events occurred. Compared with women with no migraine history, women who reported active migraine with aura had multivariable-adjusted hazard ratios of 2.15 (95% confidence interval [CI], 1.58-2.92; P<.001) for major CVD, 1.91 (95% CI, 1.17-3.10; P = .01) for ischemic stroke, 2.08 (95% CI, 1.30-3.31; P = .002) for myocardial infarction, 1.74 (95% CI, 1.23-2.46; P = .002) for coronary revascularization, 1.71 (95% CI, 1.16-2.53; P = .007) for angina, and 2.33 (95% CI, 1.21-4.51; P = .01) for ischemic CVD death.

After adjusting for age, there were 18 additional major CVD events attributable to migraine with aura per 10 000 women per year. Women who reported active migraine without aura did not have increased risk of any vascular events or angina.

It will be nice when a novel study evaluates the prevention (triptans, ASA, beta-blockers) of this association between migraine with aura and CVD.

Link to: Acetaminophen + aspirin + caffeine to treat acute attacks of migraine


Jon Mikel Iñarritu, M.D.

Early Removal of Prophylactic Drains

From Annals of Surgery

This article reminds me the risk of intraabdominal infections with a drain left there more than 4 days on the PO.

For patients with pancreatic head resection, a drain should be removed as early as the 4th PO day. This reduce the incidence of PO intraabdominal infection.

Methods: A total of 104 consecutive patients who underwent pancreatic head resection were enrolled in this study. To assess the value of prophylactic drains, we prospectively assigned the patients into 2 groups: group I underwent resection from January 2000 to January 2002 (n = 52, drain to be removed on postoperative day eight). group II underwent resection from February 2002 to December 2004 (n = 52, drain to be removed on postoperative day 4). Postoperative complications in the 2 groups were compared.
Results: The rate of pancreatic fistula was significantly lower in group II (3.6%) than in group I (23%) (P = 0.0038). The rate of intra-abdominal infections, including intra-abdominal abscess and infected intra-abdominal collections, was significantly reduced in group II (7.7%) compared with group I (38%) (P = 0.0003). Eighteen of 52 (34.6%) patients in group I had an inserted drain beyond 8 days, whereas only 2 of 52 (3.7%) patients in group II had an inserted drain beyond 4 days (P = 0.0002). Cultures of drainage fluid were positive in 16 of 52 (30.8%) patients in group I, and in 2 of 52 (3.7%) patients in group II (P = 0.0002). Intraoperative bleeding (>1500 mL), operative time (>420 minutes, and the period of drain insertion were significant risk factors for intra-abdominal infections (P = 0.043, 0.025, 0.0003, respectively). The period of drain insertion was the only independent risk factor for intra-abdominal infections by multivariate analysis (odds ratio, 6.7).
Conclusion: Drain removal on postoperative day 4 was shown to be an independent factor in reducing the incidence of complications with pancreatic head resection, including intra-abdominal infections

Jon Mikel Iñarritu, M.D.

Getting NOT enough or TOO MUCH sleep increases risk of type 2 Diabetes Mellitus

Via Diabetes Care Journal.

A cohort study (made by Yaggi, Araujo and McKinlay) who enroll men from 1987-9 to 2004 showed the next results:

Men reporting short sleep duration (< =5 and 6 h of sleep per night) were twice as likely to develop diabetes, and men reporting long sleep duration (>8 h of sleep per night) were more than three times as likely to develop diabetes over the period of follow-up.

So, If you get too much or not enough sleep, you can develop Diabetes Mellitus.

Source: Diabetes Care 2006;29:657-661.


Jon Mikel Iñarritu, M.D.