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.

• How to classify fingertip injuries and amputations and how to treat them? This is a nice abstract in where we will learn how to close the wound, maximize sensory return, preserve length, maintain joint function, and achieve a satisfactory cosmetic appearance. This is a Must Read!
• How to survive surgical training when your boss is really mean? A touching and insightful story. Luckyly those times are changing.
• How must be your surgeon? How to make the perioperative experience a smooth one for patients, nurses and surgeons? Great tips for all of us. Don’t lose the floor.
• What are the complications of Mitral Valve Replacement? An excellent reminder.
• How to choose a rehabilitation center? What are their services, facilities, costs and credentials?
• How is the clinical presentation of severe pancreatitis? I love hard cases as this one.
• How much farther have we advanced in medicine since the days of trepanation? Do you know that people had holes drilled in their heads voluntarily and they state that this results in more energy and an increased feeling of consciousness and lessens repression?
• How a prosthetic robotic arm works? Nice videos!
• How a simple procedure (lateral sphicterectomy) can lead to a satisfyingly outcome for both the patient and the surgeon?
• How to interpret the new article that assures the relationship between breast implants and suicide rates?
• How to be thankful to a surgeon and how a surgeon can change your life? Charming story that guides me to always give the best of me.
• How an amebic brain abcess looks like? You will never forget to keep it as a differential.
• How a simple order can trigger a defense mechanism? Try to not give orders to therapydoc.
• Should mesalamine be stopped prior surgery? Why?
• How to manage those the difficult situations involving CPR? A very insightful view and nicely written.
• How to back in time for 3 decades and deny the link between AIDS and VIH? Do you think that the truth may prevail?
• What kind of role a military surgeon play in war zone? Sharing his thoughts and feelings about Air Force training.

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

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.

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?

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.

Examples:

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.

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.
Regards,
Dr. Jon Mikel Iñarritu

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

Regards,

Jon Mikel Iñarritu, M.D.

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

Regards,
Jon Mikel Iñarritu, M.D.

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.

Regards,

Jon Mikel Iñarritu, M.D.