Surgery Blog for Surgeons

Work load in surgical education - impact on education and healthcare

The introduction of the 80-hours week for the residents in the USA brought a lot of unhappy faces in the faculty members. Ever since then the residents have to listen to even more "what-do-you-know" and "when-I-was-a-resident" stories on a daily basis. The generation conflict is remarkably expressed in these conversations and it is caused solely by the attending physicians. They urge the residents to protest against these rules arguing that working more than 80 hours per week is essential for a sufficient education.

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Ultrasound/MRI elastography: non-invasive test for liver fibrosis and cirrhosis

While looking for papers about "small-for-size" liver syndrome, I just stumbled upon a relatively new test called FibroScan©. This is an interesting approach in determine the stiffness of the tissue as this reflects a possible fibrosis/cirrhosis of the liver.

The test is performed by Ultra Sound (US) or MRI (the term "FibroScan©" is the commercial name of the US way only). Both methods rely on measuring the response of the liver tissue to an external vibration.

Here is a nice and short description of the tests. Rowen Zetterman points out some possible limitations:

  • "Advanced fibrosis may be underestimated and patients with macronodular cirrhosis may be classified as noncirrhotic.": I don't see this as a problem in real life because macronodular cirrhosis is easily diagnosed just by plain imaging.
  • "Fibrosis may be overestimated in patients with extrahepatic cholestasis or acute hepatocellular injury due to the effects of these conditions on liver stiffness.": I would add here also CHF as it makes a liver stiff as well.
  • "Ultrasound elastography does not distinguish patients with no fibrosis from patients with minimal fibrosis.": Yes, this is understandable. But there is probably no clinical relevance of this distinction.
  • "Ascites can interfere with the generation of a shear wave through the liver.": At the stage of significant ascites, the patients usually have some sort of diagnosis. But I agree that this is a real limitation of the test.

Having those limitations in mind, I think that overall this is a very nice idea. We are challenged now to get some sensitivity and specificity so that we could find the group of patients who could avoid the biopsy.

Happy Holidays!

Everyone who sporadically was or regularly is stopping by, I would like to wish Happy Hanukkah, Merry Christmas or whatever you celebrate these days.

Here is my holiday's gift for you: a very nice surgical story I recently heard.

One of my colleagues told me recently about his father who was a surgeon in the Vietnam War. Back then he (the father) was a youngster and used to work with an elderly surgeon who used to... switched off (!) the lights for 2 minutes before closing the skin. On every case!

The rationale behind this (for us) obviously queer custom was the following.
The postoperative bleedings occur because the vessels start to bleed after the closure of the skin. So, to "trap" them, the old surgeon tried to make them "think" the skin was already closed. After 2 minutes he switched the lights back on and looked for any vessel which might have disclosed itself as a potential troublemaker.

People think about medicine as a science. But there are so many "voodoos" we do.

Being a good surgeon becomes a challenging task if you want to keep up with the recent news in this field and also in the world. Having a "normal" social life is increasingly difficult when you consider the time spent in the OR, taking care of the patients and reading the literature.

This is why I truly appreciate you visiting this blog. Thank you!

Hyperacute rejection in liver transplantation?

The hyperacute rejection in transplant surgery is a devastating event. Prior to the introduction of the crossmatch for kidney transplantation, the hyperacute rejection was not uncommon. However the crossmatch is currently of no importance in the organs other than the kidney.
Despite some published case reports, most transplant surgeons do not even believe in hyperacute (or also antibody-mediated) rejection in liver allotransplantation. In fact, this attitude has been almost supported by most of these papers - they are just not convincing!

Having written the above, I will describe here a case that I have no (other) explanation for its course.

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Anemia and blood transfusions

Acute anemia is a common reason for transfusion of blood products. The hemoglobin (Hb) threshold for correcting anemia has been a hot topic of discussions for a long time. Here I would like to share my experience and thoughts about this very surgical issue.

About 15 years ago I listened to a talk that was given by a German gastroenterologist who worked at that time in Malawi, a small country in the southern part of Africa. Among other interesting stories, he said that they did not even think about blood transfusion unless there is the number 4 (four!) before the dot/comma in the Hb g/dl level. This was due to a relative lack of blood products but he said also that they never had any problems related to uncorrected acute anemia.
We should assume though, that most of the patients there are generally in a better health that the average patient in the Western world, mostly because of the short life expectancy and very low rate of chronic diseases like Diabetes or Hypertension. Also, as one of my current mentors noted, the rate of patients with sickle cell anemia might be significantly higher there. These patients tend to tolerate much lower Hb levels.

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The process of organ procurement: Liver - the cold dissection

This is the third part of the posting series "The process of organ procurement".
Please start with the first and second parts if you have not done so.

The cold dissection is the part with the most surgical variants and I want to stress again the fact that the described way is the one that I use, well knowing that this is only one of many possible ways to perform an organ procurement in general and a cold dissection in particular.

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The process of organ procurement: Liver - the warm dissection

This is the second part of the posting series "The process of organ procurement".
Please start with the first part if you have not done so.

The preparation in the OR includes placing of two electrocautery ("Bovie") pads and two suction lines.

I usually fixate both arms next to the body unless the anesthesia colleagues have a good reason for extending one or both of them. Shaving and decontamination of the skin I perform only in a line about 5-10 cm on both sides of the midline as I never make lateral incisions.

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The process of organ procurement: prior to the surgery

There are many ways performing most of the surgical procedures. Everyone of the surgeons has established a way to go for a particular surgery that s/he is most familiar with and trusts most. In this series of postings ("The process of organ procurement") I will describe the way I perform the liver and kidney procurements in a Standard Criteria Donation (SCD) situation.

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Metastasis dependancy on the primary tumor?

Recently I had an interesting case with a weird behavior of a suspected metastasis after resection of the primary tumor.

A 43 years old gentleman came in July 2008 to the Medical Service with nausea, vomiting and abdominal pain. The workup showed a tumor in the 3rd portion of the duodenum as well as a big mass in the right liver lobe, so the IM guys asked us to take a look. They performed two attempts to biopsy the masses which showed no tumor. This was the reason for the decision to resect the tumor.

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Michael DeBakey is dead!

Michael DeBakey died at the age of 99.

Michael E. DeBakey, MD

This surgeon published his first invention in 1933 and had an office at the Baylor College in Houston until his death yesterday (In Memoriam, Michael E. DeBakey, MD).

My former chief retired about a year ago and at the same day I left also the Medical Center where he and Dr. Thorsten Morlang made me a surgeon. At a ceremony for his retirement, Prof. Dr. Wolf J. Stelter (a 1994 president of the Michael E. DeBakey International Surgical Society) showed then pictures of his own chiefs through the years in different medical centers in Germany and in the United States. He started talking about them saying that, of all these men, only Michael DeBakey is still alive.
...And I was happy that my chief is alive.

Until some hours ago Michael DeBakey was a living legend... I can't write any more about this.

Rest in peace, Dr. DeBakey!