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This study assessed the reliability of surgical resident self-assessment in comparison with faculty and standardized patient (SP) assessments during a structured educational module focused on perioperative management of a simulated adverse event. Seven general surgery residents participated in this module. Residents were assessed during videotaped preoperative and postoperative SP encounters and when dissecting a tumor off of a standardized inanimate vena cava model in a simulated operating room. Preoperative and postoperative assessments by SPs correlated significantly ( P < .05) with faculty assessments (r = .75 and r = .79, respectively), but not resident self-assessments. Coefficient alpha was greater than .70 for all assessments except resident preoperative self-assessments. Faculty and SP assessments can provide reliable data useful for formative feedback. Although resident self-assessment may be useful for the formative assessment of technical skills, results suggest that in the absence of training, residents are not reliable self-assessors of preoperative and postoperative interactions with SPs.

Whether clinically stable small abdominal aortic aneurysms should be surgically repaired or monitored with periodic noninvasive imaging is controversial. This study compared the two approaches in patients with aneurysms 4.0 to 5.4 cm in diameter. After a mean follow-up of nearly five years, there was no survival advantage associated with immediate surgical repair. This study compared the two approaches in patients with aneurysms of 4.0 to 5.4 cm. There was no survival advantage with immediate surgical repair. Each year in the United States, 9000 deaths result from rupture of abdominal aortic aneurysms. 1 Another 33,000 patients undergo elective repair of asymptomatic abdominal aortic aneurysms to prevent rupture, which results in 1400 to 2800 operative deaths. 2 , 3 Because most abdominal aortic aneurysms never rupture, 4 elective repair is undertaken only when the risk of rupture is considered high. The strongest known predictor of rupture is the maximal diameter of the aneurysm. 5 , 6 Elective repair has been recommended for patients with aneurysms of 4.0 cm or more in diameter who do not have medical contraindications, 7 although others have advocated the use . . .

This pilot project involved the development of a structured, experiential, educational module using a bench model technical skills simulation and standardized patients. It integrated teaching and assessment of clinical, technical, and interpersonal skills, as well as professionalism within the context of an adverse surgical event. General surgery residents (postgraduate year [PGY] 2, 3) were asked to participate in the pre-, intra-, and postoperative management of a patient with a retroperitoneal sarcoma. Residents’ performances during the module were assessed by standardized patients and faculty, and residents were provided feedback during debriefing sessions. Resident performance during the module was appropriate for the level of training. Residents found this module to be a realistic, challenging, and beneficial learning experience. Novel educational modules such as this one may serve as a useful addition to resident education in surgery residency programs, particularly in addressing patient safety and the core competencies. Reliability of the model may be enhanced by modifications of the module.

Currently, the two primary approaches to carotid endarterectomy for extracranial carotid stenosis are carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. In a retrospective study over a 4-year period from 1998 to 2002, we had an opportunity to compare the two approaches as two surgeons utilized carotid endarterectomy with Dacron patch angioplasty and two other surgeons utilized eversion carotid endarterectomy. During the 4-year period, 189 carotid endarterectomies were performed, 125 with Dacron patch angioplasty (CE-P) and 64 with eversion (EE) endarterectomy. There were no significant differences in age of the patients, operative indication, or associated risk factors between the two groups. Perioperative outcome measurement in the CE-P versus EE included stroke or transient ischemic attack, 1.6 per cent versus 1.56 per cent, cranial nerve injury, 2.4 per cent versus 3.13 per cent; death, 0.8 per cent versus 0 per cent; need for operative conversion or revision, 2.4 per cent versus 7.81 per cent, respectively. Only the need for operative conversion or revision reached significant difference (P < 0.05), although the need decreased to 4 per cent for the last 50 EE cases. Recurrent stenosis of 50 per cent to 79 per cent was 4.88 per cent versus 3.13 per cent and >80 per cent was 0.81 per cent versus 0 per cent in the CE-P versus EE group over a follow up of 16.3 months and 17.0 months, respectively. We conclude that both CE-P and EE are equally efficacious operative approaches to extracranial carotid occlusive disease.

Currently, the two primary approaches to carotid endarterectomy for extracranial carotid stenosis are carotid endarterectomy with patch angioplasty and eversion carotid endarterectomy. In a retrospective study over a 4-year period from 1998 to 2002, we had an opportunity to compare the two approaches as two surgeons utilized carotid endarterectomy with Dacron patch angioplasty and two other surgeons utilized eversion carotid endarterectomy. During the 4-year period, 189 carotid endarterectomies were performed, 125 with Dacron patch angioplasty (CE-P) and 64 with eversion (EE) endarterectomy. There were no significant differences in age of the patients, operative indication, or associated risk factors between the two groups. Perioperative outcome measurement in the CE-P versus EE included stroke or transient ischemic attack, 1.6 per cent versus 1.56 per cent, cranial nerve injury, 2.4 per cent versus 3.13 per cent; death, 0.8 per cent versus 0 per cent; need for operative conversion or revision, 2.4 per cent versus 7.81 per cent, respectively. Only the need for operative conversion or revision reached significant difference (P < 0.05), although the need decreased to 4 per cent for the last 50 EE cases. Recurrent stenosis of 50 per cent to 79 per cent was 4.88 per cent versus 3.13 per cent and >80 per cent was 0.81 per cent versus 0 per cent in the CE-P versus EE group over a follow up of 16.3 months and 17.0 months, respectively. We conclude that both CE-P and EE are equally efficacious operative approaches to extracranial carotid occlusive disease. [PUBLICATION ABSTRACT]

Our objective was to review the results of carotid endarterectomies (CEAs) with Dacron patch angioplasty and intraoperative color-flow duplex scanning (CFS). In a 3-year period, patients who underwent CEA with Dacron patch angioplasty and intraoperative CFS were studied. We excluded patients who had primary closure, vein patch, and redo endarterectomy. Serial CFS was obtained first in the early postoperative period (one day to 3 weeks), then at 6 months, and then yearly. Intraoperative CFS abnormalities were classified as major, requiring immediate revision, or minor, which were observed. The diagnosis of recurrent stenosis by US was based on the detection of an increased peak systolic frequency (>8000 MHz) or velocity (>250 cm/second) in the internal carotid artery. There were 212 CEAs performed in 200 patients (128 men and 84 women) included in this study. Three patients (1.4%) awoke with a stroke, two (0.94%) had transient ischemic attacks, and three (1.4%) developed transient hypoglossal nerve paresis. Intraoperative CFS showed a major defect that required an immediate revision in six patients (2.8%). Minor abnormalities were detected in another 41 patients (19.3%), but no revision was necessary. In follow-up three patients were identified with a severe recurrent carotid stenosis (>80%) and they underwent redo CEA. This rate of recurrence (1.4%) is significantly lower than the rate we had previously reported in a larger study (82 of 1209, 6.8%; P = 0.003). We conclude that the combined use of Dacron patch angioplasty and intraoperative CFS after CEA is associated with a low perioperative morbidity and a low incidence of recurrent stenosis in the first 2 years after operation.

Because an integral part of the vascular examination involves palpation of peripheral pulses the applicability of telemedicine (TM) for the evaluation of vascular surgery patients is open to question. Endean et al test the hypothesis that TM is as effective as direct patient examination for the development of a care plan in vascular patients.

Mansour et al review the results of carotid endarterectomies (CEAs) with Dacron patch angioplasty and intraoperative color-flow duplex scanning (CFS). The results indicate that the combined use of Dacron patch angioplasty and intraoperative CFS after CEA is associated with a low perioperative morbidity and a low incidence of recurrent stenosis in the first 2 years after operation.

Intermittent pneumatic compression (IPC) is effective in deep venous thrombosis prophylaxis. IPC prevents venous stasis by collapsing the peripheral venous plexus in an extremity leading to increased venous return. It has been suggested that IPC has an additional effect of enhancing fibrinolysis. This study was designed to evaluate the effect of IPC on both systemic and local fibrinolysis in normal volunteers by measuring the activity of tissue plasminogen activator (t-PA) and plasminogen activator inhibitor-type 1 (PAI-1). In addition, tissue factor pathway inhibitor (TFPI) was measured to assess changes in the extrinsic coagulation cascade. IPC was applied in the foot and calf of 10 healthy subjects and blood was drawn from the antecubital fossa to determine systemic fibrinolytic activity. Local fibrinolysis was assessed in 15 healthy subjects by placing an IPC cuff on the forearm and drawing blood 2 cm above the cuff The IPC maximum inflation pressure was 120 mm Hg lasting for 3 seconds at three cycles per minute. Blood samples were taken at rest, on the 10th minute of active IPC, and 5 minutes after cessation of IPC for both systemic and local measurements. The plasma was analyzed for TFPI, t-PA, and PAI-1 antigen by use of enzyme-linked immunosorbent assays. There were no significant changes in systemic or local fibrinolytic activity before, during, or after application of IPC. TFPI systemic activity before, during, and after was 111 ±24, 118 + 18, and 116 ±22, respectively. Local TFPI activity was 91 ±32, 93 +36, and 91 ± 24, respectively. The t-PA systemic activity before, during, and after was 4.1 ± 1.9, 4.7 ± 2.3, and 5 + 2.8, respectively. Local t-PA activity was 4.5 ± 1.3, 4.5 ± 1.4, and 4.2 ± 1.4, respectively. Systemic PAI-1 activity was 11 ± 9.2, 17 ± 19, and 17 ±31, respectively. Local PAI-I activity was 3.7 ± 3.1, 3 ± 1, and 2.8 + 1, respectively, p > 0.38 for all comparisons in both groups. No evidence was found that IPC enhances systemic and local fibrinolysis or TFPI release. Irrespective of the length of IPC application or the inflation pressure, several studies have reported increased fibrinolysis, whereas others have not found any changes. Although, according to the literature, there is a trend toward increased fibrinolytic activity, further controlled studies with adequate sample size should be performed to provide an answer to this controversial topic.