Specific Competence of Surgical Leadership
Surgeons are uniquely prepared to assume leadership roles because of their position in the operating room (OR). Whether they aspire to the title or not, each and every surgeon is a leader, at least within their surgical team. Their clinical responsibilities offer a rich variety of interpretations that prepare them for a broader role in health care leadership. They deal directly with patients and their families, both in and out of the hospital setting, seeing a perspective that traditional health care administrative leaders rarely experience. They work alongside other direct providers of health care, in varied settings, at night, on weekends, as well as during the typical workday. They understand supply-chain management as something more than lines on a spreadsheet.
The Challenges for a Surgical Leader
Surgeons prefer to lead, not to be led. Surgical training has traditionally emphasized independence, self-reliance, and a well-defined hierarchy as is required in the OR. However, this approach does not work well outside the OR doors. With colleagues, nurses, staff, and patients, they must develop a collaborative approach. Surgeons are entrusted with the responsibility of being the ultimate decision maker in the OR. While great qualities in a surgeon in the OR, it hinders their interactions with others. They have near-absolute authority in the OR, but struggle when switching to a persuasive style while in committees and participating in administrative activities. Most surgeons do not realize they are intimidating to their patients and staff. With patients, a surgeon needs to be empathetic and a good listener. A surgeon needs to slow the pace of the discussion so that the patient can understand and accept the information they are receiving. As perfectionists, surgeons demand a high level of performance of themselves. This sets them up for exhaustion and burnout, becoming actively disengaged, going through the motions, but empty on the inside. Given the many challenges surgeons face, it is difficult for them to understand the leadership role, given its complex demands.
Specific Competencies
Authority
Although teams and all team members provide health care should be allowed input, the team leader makes decisions. The leader must accept the responsibility of making decisions in the presence of all situations. They will have to deal with conflicting opinions and advice from their team, yet they must accept that they will be held accountable for the performance of their team. The surgeon–leader cannot take credit for successes while blaming failures on the team. Good teamwork and excellent communication do not relieve the leader of this responsibility.
Leadership Style
A surgeon often has a position of authority based on their titles or status in an organization that allows them to direct the actions of others. Leadership by this sort of mandate is termed “transactional leadership” and can be successful in accomplishing specific tasks. For example, a surgeon with transactional leadership skills can successfully lead a surgical team through an operation by requesting information and issuing directives. However, a leader will never win the hearts of the team in that manner. The team will not be committed and follow through unless they are empowered and feel they are truly heard. A transformational leader is one who inspires each team member to excel and to take action that supports the entire group. If the leader is successful in creating a genuine atmosphere of cooperation, less time will be spent giving orders and dealing with undercurrents of negativity. This atmosphere can be encouraged by taking the time to listen and understand the history behind its discussion. Blame should be avoided. This will allow the leader to understand the way an individual thinks and the group processes information to facilitate the introduction of change. While leadership style does not guarantee results, the leader’s style sets the stage for a great performance. At the same time, they should be genuine and transparent. This invites the team members to participate, creating an emotional connection. Leaders try to foster an environment where options are sought that meet everyone’s desires.
Conflict Management
Conflict is pervasive, even in healthy, well-run organizations and is not inherently bad. Whether conflict binds an organization together or divides it into factions depends on whether it is constructive or destructive. A good leader needs to know that there are four essential truths about conflict. It is inevitable, it involves costs and risks, the strategies we develop to deal with the conflict can be more damaging than the conflict itself, and conflict can be permanent if not addressed. The leader must recognize the type of conflict that exists and deal with the conflict appropriately. Constructive discussion and debate can result in better decision making by forcing the leader to consider other ideas and perspectives. This dialog is especially helpful when the leader respects the knowledge and opinions of team members with education, experience, and perspective different from the leader’s. Honesty, respect, transparency, communication, and flexibility are all elements that a leader can use to foster cohesion while promoting individual opinion. The leader can create an environment that allows creative thinking, mutual problem solving, and negotiation. These are the hallmarks of a productive conflict. Conflict is viewed as an opportunity, instead of something to be avoided.
Communication Skills
Communication is the primary tool of a successful leader. On important topics, it is incumbent on the leader to be articulate, clear, and compelling. Their influence, power, and credibility come from their ability to communicate. Research has identified the primary skills of an effective communicator. They are set out in the LARSQ model: Listening, Awareness of Emotions, Reframing, Summarizing, and Questions. These are not set in a particular order, but rather should move among each other freely. In a significant or critical conversation, it is important for a leader to listen on multiple levels. The message, body language, and tone of voice all convey meaning. You cannot interrupt or over-talk the other side. They need an opportunity to get their entire message out. Two techniques that enhance listening include pausing and the echo statement. Pausing before speaking allows the other conversant time to process what they have said to make sure the statement is complete and accurate. Echo statements reflect that you have heard what has been said and focuses on a particular aspect needing clarification. Good listening skills assure that the leader can get feedback that is necessary for success.
Vision, Strategy, Tactics, and Goals
One of the major tasks of a leader is to provide a compelling vision, an overarching idea. Vision gives people a sense of belonging. It provides them with a professional identity, attracts commitment, and produces an emotional investment. A leader implements vision by developing strategy that focuses on specific outcomes that move the organization in the direction of the vision. Strategy begins with sorting through the available choices and prioritizing resources. Through clarification, it is possible to set direction. Deficits will become apparent and a leader will want to find new solutions to compensate for those shortfalls. For example, the vision of a hospital is to become a world class health care delivery system. Strategies might include expanding facilities, improving patient satisfaction, giving the highest quality of care, shortening length of hospital stay with minimal readmissions, decreased mortality, and a reduction in the overall costs of health care. Tactics are specific behaviors that support the strategy with the aim to achieve success. Tactics for improving patient satisfaction may include reduced waiting time, spending more time with patients, taking time to communicate in a manner that the patient understands, responding faster to patient calls, etc. These tactics will then allow a leader to develop quantitative goals. Patient satisfaction can be measured. The surgical leader can then construct goals around each tactic, such as increasing satisfaction in specific areas. This information allows a surgical leader to identify barriers and they can take steps to remedy problem areas. This analysis helps a leader find the weakest links in their strategies as they continue toward achieving the vision.
Change Management
The world of health care is in continuous change. The intense rate of political, technical, and administrative change may outpace an individual’s and institution’s ability to adapt. Twenty-first century health care leaders face contradictory demands. They must navigate between competing forces. Leaders must traverse a track record of success with the ability to admit error. They also must maintain visionary ideas with pragmatic results. Individual accountability should be encouraged, while at the same time facilitating teamwork. Most leaders do not understand the change process. There are practical and psychological aspects to change. From an institutional perspective, we know that when 5% of the group begins to change, it affects the entire group. When 20% of a group embraces change, the change is unstoppable.
Succession Planning and Continuous Learning
An often-overlooked area of leadership is planning for human capital movement. As health care professionals retire, take leaves of absences, and move locations, turmoil can erupt in the vacuum. Leaders should regularly be engaging in activities to foster a seamless passing of institutional knowledge to the next generation. They also should seek to maintain continuity to the organization. Ways to accomplish this include senior leaders actively exposing younger colleagues to critical decisions, problem solving, increased authority, and change management. Leaders should identify promising future leaders, give early feedback for areas of improvement, and direct them toward available upward career tracks. Mentoring and coaching help prepare the younger colleagues for the challenges the institution is facing. Teaching success at all levels of leadership helps create sustainable high performance.
Gallstone Ileus
INTRODUCTION
Gallstone ileus is a misnomer: this condition is not a physiologic ileus at all, but a mechanical obstruction of the intestinal lumen (most commonly the small bowel) by a large gallstone that has passed through a cholecystoenteric fistula. Cholecystoenteric fistulae may occur from the gallbladder to the adjacent luminal viscera-duodenum (most common), stomach, or colon. Gallstone obstruction of the stomach at the pylorus is known as Bouveret’s syndrome. Cholecystocolic fistula is less common. Colonic obstruction in this situation typically occurs at the sigmoid colon. Most common is cholecystoduodenal fistula, with a large (usually >2 cm) gallstone passing through the small bowel and becoming lodged in the terminal ileum. Cholecystoenteric fistula is felt to be caused by a combination of pressure, necrosis, and inflammation with chronic longstanding gallstone disease. Up to 25% of patients who develop gallstone ileus will harbor multiple stones in the alimentary tract; therefore, a close inspection of the entire intestine is important at the time of operation.
CLINICAL PRESENTATION
Over the past few years, however, the incidence of gallstone ileus has been shown to be greater than previously thought. Several recent large population-based series have found that gallstone ileus accounts for approximately 0.1% of all small bowel obstructions. The disease usually affects women (70%) and those in the seventh or eighth decade of life. Most patients present with bloating, crampy abdominal pain, and vomiting, symptoms typical of mechanical small bowel obstruction. A careful history may reveal earlier episodic colicky right upper quadrant abdominal pain consistent with gallstone disease. The classic finding on plain abdominal radiograph is that of Rigler’s triad (pneumobilia, dilated small bowel loops with air-fluid levels, and a large, calcified gallstone in the lumen of the small bowel). Currently, computed tomography (CT) is used ubiquitously. CT has 99% accuracy for diagnosing gallstone ileus. Typical CT findings include pneumobilia, dilated loops of small bowel with air-fluid levels consistent with small bowel obstruction, and transition point with the ectopic stone always visible radiologically.
MANAGEMENT
Operation is required for all patients with gallstone ileus, as spontaneous passage of these large stones is rare once the patient has become symptomatic. It is crucial to optimize the patient physiologically as much as possible in this semi urgent situation, with the understanding that most gallstone ileus patients are elderly and commonly have numerous medical comorbidities. Two contemporary series of registry data have expanded our understanding of gallstone ileus. This condition was once thought to be relatively rare; however, the National Inpatient Sample study identified 3268 gallstone ileus patients, which accounts for approximately 0.1% of all patients admitted to the hospital with mechanical small bowel obstruction during this time period. In this series, overall hospital mortality was substantial at 6.7%. Mortality was significantly higher in patients who underwent cholecystectomy and closure of the biliary fistula compared to those who simply had small bowel obstruction addressed by cholecystolithotomy. Overall, 77% of the 3268 patients had small bowel obstruction pathology treated and the remaining 23% had biliary fistula closed and cholecystectomy at the same operation. An interesting finding was the substantial incidence of postoperative renal insufficiency, or approximately 30% in the entire group of patients. The latter finding highlights the need for preoperative resuscitation and close attention to postoperative fluid management. The surgeon must consider carefully feasibility of same operation intervention to repair biliary pathology: It is safe to defer biliary operation to a later date with a second staged operation. When this strategy of two stage operation is selected, surgeons should consider and counsel their patient regarding the substantial incidence of recurrent biliary symptoms.
Tratamento Cirúrgico da ACALASIA ESOFÁGICA
A acalasia, definida como a falha ou relaxamento incompleto do esfíncter esofágico inferior (EEI), acompanhada de aperistalse do corpo esofágico na ausência de obstrução mecânica, é o tipo mais comum de distúrbio da motilidade esofágica. Tem uma incidência de 1 em 100.000 pessoas, com uma prevalência de 10 em 100.000. Não há diferença na prevalência de gênero entre as idades de 30 e 60 anos. A causa primária da acalasia ainda é indeterminada, mas acredita-se que surja da degeneração das células ganglionares inibitórias no plexo miontérico do EEI e corpo esofágico. Fatores associados a um risco aumentado de acalasia incluem distúrbios virais/neurodegenerativos, síndrome de Down, diabetes mellitus tipo 1, hipotireoidismo e condições autoimunes, como a síndrome de Sjögren, o lúpus eritematoso sistêmico e a uveíte. Os casos familiares são raros.
O diagnóstico de acalasia deve ser suspeitado em pacientes com disfagia para sólidos e líquidos que não melhora com o uso de inibidores da bomba de prótons. Se não for tratada, a acalasia é uma doença progressiva que pode evoluir para megaesôfago e está associada a um aumento do risco de carcinoma de células escamosas do esôfago. Embora não existam critérios padronizados para determinar a gravidade da doença, o diâmetro e a confirmação do esôfago dentro da cavidade torácica são geralmente considerados os dois principais fatores. A escala de Eckardt é uma escala frequentemente usada para avaliar a gravidade da doença e a eficácia da terapia. Qualitativamente, a acalasia grave é definida como um diâmetro esofágico maior que 6 cm; a acalasia em estágio avançado inclui a angulação distal, um esôfago sigmóide/tortuoso com diâmetro maior que 6 cm ou um megaesôfago com diâmetro maior que 10 cm. Aproximadamente 5% a 15% das pessoas com acalasia evoluem para acalasia em estágio avançado, são geralmente resistentes aos tratamentos endoscópicos e cirúrgicos iniciais e, em última instância, requerem uma esofagectomia.
MIOTOMIA Á HELLER
A miotomia laparoscópica de Heller (LHM) com fundoplicatura parcial, desenvolvida como uma alternativa minimamente invasiva à miotomia anterior aberta tradicional e posteriormente à miotomia toracoscópica, tem sido o padrão ouro para o tratamento da acalasia nas últimas três décadas. O objetivo da miotomia é abrir completamente o EEI e aliviar a disfagia. A LHM proporciona alívio sintomático inicial da disfagia em cerca de 90% dos pacientes com tipos I e II de acalasia e em 50% dos pacientes com tipo III de acalasia, enquanto diminui as taxas de refluxo pós-operatório. Em comparação com os procedimentos de miotomia aberta, a LHM está associada a menor dor pós-operatória, menor tempo de internação hospitalar e retorno mais precoce à função. A LHM é indicada como tratamento de primeira linha para todos os candidatos à cirurgia com acalasia que estejam dispostos a se submeter à cirurgia ou para aqueles que falharam na dilatação endoscópica. A operação consiste em dividir os músculos do EEI, seguida por uma fundoplicatura para diminuir o refluxo pós-operatório. A fundoplicatura parcial é favorecida em relação à fundoplicatura total porque reduz a falha do tratamento. As duas principais complicações da cirurgia são perfuração da mucosa e DRGE.
Surgical Management of Chronic Pancreatitis
Chronic pancreatitis is a progressive, destructive inflammatory process that ends in destruction of the pancreatic parenchyma resulting in malabsorption, diabetes mellitus, and severe pain. The etiology of chronic pancreatitis is multifactorial. About 65–70% of patients have a history of alcohol abuse, the remaining patients are classified as idiopathic chronic pancreatitis (20–25%), including tropical pancreatitis, a major cause of childhood chronic pancreatitis in tropical regions, or unusual causes including hereditary pancreatitis, cystic fibrosis, and chronic pancreatitis-associated metabolic and congenital factors. Current evidence suggests that a combination of predisposing factors, including environmental, toxic, and genetic, are involved in most patients rather than one single factor. The best-known hypotheses about the pathogenesis of chronic pancreatitis include necrosis-fibrosis, toxic-metabolic, oxidative stress, plug and stone formation with duct obstruction, and primary duct obstruction. Repeated episodes of inflammation initiated by autodigestion, one or more episodes of severe pancreatitis, oxidative stress, and/or toxic-metabolic factors lead to activation and continued stimulation of parenchymal pancreatic stellate cells. These stellate cells cause the fibrosis characteristic of chronic pancreatitis. Nevertheless, multiple hypotheses exist to explain the pathophysiology in the various subgroups of patients with chronic pancreatitis, but to date there is no single unifying theory.
OPERATIVE TREATMENT
There are several different concepts for the operative treatment of chronic pancreatitis. The concept of preservation of functioning pancreatic parenchyma (drainage operations) would be the goal for protection against further loss of pancreatic function. The second main concept is based on resective procedures either in the situation where there is no dilation of the pancreatic duct, if the pancreatic head is enlarged, or if a pancreatic carcinoma is suspected in the setting of chronic pancreatitis. These two concepts involve different operative procedures.
Drainage procedures
Sphincterotomy of the pancreatic duct was one of the first operative procedures proposed for patients with a dilated pancreatic duct in chronic pancreatitis with presumed obstruction or stenosis at the papilla Vater. Unfortunately, this procedure was associated with minimal lasting success for the amelioration of pain, indicating that a stenosis at the papilla of Vater is not the cause of pain in chronic pancreatitis nor the cause of ductal dilation. In contrast, direct ductal-enteric drainage by the original Puestow procedure or its modification by Partington and Rochelle is more successful in patients with chronic pancreatitis and a dilated pancreatic duct. The original Puestow procedure included resection of the tail of the pancreas with filleting open the pancreatic duct proximally along the body of the pancreas with anastomosis to a Roux-en-Y loop of jejunum. Partington and Rochelle modified the Puestow procedure by eliminating the resection of the pancreatic tail. A recent procedure involves a wedge-shaped opening of the pancreatic duct (even when the duct is <5 mm) with a subsequent pancreatico-jejunostomy. The preservation of functional tissue and reduction of operative mortality to less than 1% and morbidity to less than 10% are the goals and benefits of this operation. Unfortunately, large series have reported persistence or recurrence of pain at long-term follow up (>5 year) in 30–50% of patients; in addition, patients with a dominant mass in the head of the pancreas and a non-dilated pancreatic duct do not appear to profit from a drainage procedure at all. A recent randomized controlled trial demonstrated that operative drainage in selected patients with a large duct was more effective than endoscopic treatment in patients with obstruction of the pancreatic duct.
Pancreatic Resections
Pancreatoduodenectomy (Kausch-Whipple procedure). For many surgeons, a pancreatoduodenectomy is the gold standard for patients with the pain of chronic pancreatitis, although the newer, duodenum-preserving procedures are good (and possibly better) alternatives as well (see below). The approach of resection of the proximal gland is based on Longmire’s tenet that the ‘‘pacemaker’’ of pain is in the head of the pancreas. The indications for pancreatoduodenectomy in patients with chronic pancreatitis and pain are:
(1) a non-dilated pancreatic duct (diameter < 6 mm measured in the body of the gland),
(2) an enlarged head of the pancreas, often containing cysts and calcifications,
(3) a previous, ineffective ductal drainage procedure, and/or
(4) when there is the possibility of malignancy in the head of the gland.
This latter subgroup comprises up to 6–10% of patients undergoing operative intervention for chronic pancreatitis. After pancreatoduodenectomy, > 80% of patients have permanent pain relief, which is greater than after a drainage operation. In experienced centers, a pancreatoduodenectomy can be performed with a low operative mortality rate (< 2%), and a morbidity of 40%. Although the classic pancreatoduodenectomy has these advantages, there is some long-term morbidity in chronic pancreatitis patients, especially regarding quality of life. In addition to development of diabetes, patients experience postoperative digestive dysfunction, including dumping, diarrhea, peptic ulcer, and dyspeptic complaints. To address these effects of the classic pancreatoduodenectomy which involved a distal gastrectomy, ‘‘organ-preserving’’ operations like the pylorus-preserving pancreatoduodenectomy. Symptoms of dumping and bile-reflux gastritis can be decreased by preserving the stomach, the pylorus, and the first part of the duodenum. In addition, regarding quality of life, a pylorus-preserving technique provides better results than the classic pancreatoduodenectomy procedure; weight gain occurs in 90% of the patients postoperatively while still leading to long-lasting pain relief in 85–90% of the patients. Pylorus-preserving resections, however, appear to have a greater incidence of transient delayed gastric emptying postoperatively (20–30% of the patients) as well as the risk of cholangitis and the long-term occurrence of exocrine and endocrine pancreatic insufficiency (seen in >45% of patients), representing the possible drawbacks of this operation in chronic pancreatitis patients. The relevant studies (level I and II) comparing classic with pylorus preserving pancreatoduodenectomy could not demonstrate a clear advantage for either resection. One should remember, however, that pancreatoduodenectomy was originally introduced to treat malignant pancreatic or periampullary disease by an oncologic resection. Therefore, for a benign disorder such as chronic pancreatitis, there is no reason – other than the occasional inability to exclude pancreatic cancer definitely – to remove peripancreatic organs (the distal stomach, the duodenum, and the extrahepatic bile ducts), which are involved only secondarily in chronic pancreatitis. This concept stimulated the development of organ-preserving pancreatic resections.
Duodenum-preserving pancreatic head resection (DPPHR).
This procedure addresses patients with a dominant mass in the head of the pancreas with or without a dilated main pancreatic duct. The duodenum-preserving resection (Beger procedure) includes a ventral dissection and dorsal mobilization of the head of the pancreas. After division of the pancreas anterior to the porto-mesenteric vein (as with a pancreatoduodenectomy), the resection is carried out toward the papilla of Vater. A subtotal resection of the pancreatic head is carried out leaving a small margin of pancreatic tissue associated with the duodenum containing the common bile duct; a small rim of pancreatic tissue toward the vena cava should be preserved as well during removal of most all of the uncinate process. In most patients, it is possible to free the bile duct from the surrounding scarring without disrupting continuity with the ampulla of Vater, thereby avoiding the need for a bilio-digestive anastomosis.
In some patients (20%), the common bile duct is obstructed and should be opened, so that the bile will drain into the cavity of the resected pancreatic head which is drained into a Roux-en-Y limb of jejunum. The standard reconstruction consists of a Roux-en- pancreaticojejunostomy to the distal pancreatic remnant (body and tail of pancreas) and a pancreatojejunostomy to the rim of pancreas at the duodenum (including the opened bile duct if needed). In up to 10% of patients, this DPPHR procedure is combined with a lateral pancreaticojejunostomy to drain multiple stenoses of the main pancreatic duct. The mortality rate is low (1%), and the morbidity rate is around 15%, less than after pancreatoduodenectomy.
When compared with pancreatoduodenectomy in patients with chronic pancreatitis, the DPPHR offers the advantage of preserving the duodenum and extrahepatic biliary tree, and its superiority over even the pylorus-preserving resection has been shown in prospective studies. Patients who underwent the DPPHR had greater weight gain, a better glucose tolerance, and a higher capacity for insulin secretion. In long-term follow-up, about 20% of the patients developed new onset of diabetes mellitus, like the incidence of diabetes after pancreatoduodenectomy. There is some evidence that endocrine function may be better preserved after DPPHR when compared with patients with chronic pancreatitis not undergoing operation, secondary to the relief of pancreatic ductal obstruction/hypertension. Regarding pain status, 90% of patients after DPPHR have long-term relief of pain. Regarding quality of life, 69% of the patients in one study were rehabilitated professionally, 26% retired, and only 5% of the patients were unimproved. Considering the better pain status, a lesser frequency of acute episodes of chronic pancreatitis, especially in those patients with an enlarged pancreatic head, marked decrease in the need for further hospitalization, low early and late mortality rate, and the restoration of a better quality of life, evidence suggests that DPPHR may delay the natural course of the disease of chronic pancreatitis.
The DPPHR was modified by Frey and colleagues to include a longitudinal pancreatico-jejunostomy combined with a local ‘‘coring out’’ of the pancreatic head without the need for an extensive dissection near the superior mesenteric vessels as with the DPPHR. The Frey and DPPHR have undergone evaluation in multiple comparative trials, confirming their effectiveness as operative procedures for chronic pancreatitis. A modified technique (Bern procedure) of the Beger and Frey procedures has been described recently in patients with chronic pancreatitis. This extended Frey procedure combines the advantages of the Beger and Frey procedure by maintaining a non-anatomic, subtotal central pancreatic head resection but without the need for transsection of the gland over the superior mesenteric vein (SMV), the most tedious part of the DPPHR procedure which was the major advantage offered by the Frey procedure. This modified technique reduces the risk of intraoperative bleeding which is especially increased in the presence of portal hypertension.
Left-sided pancreatic resection (distal pancreatectomy)
Most surgeons believe that the pancreatic head is the pacemaker in chronic pancreatitis, and therefore, pancreatic head resections should be the target for most patients with chronic pancreatitis affecting the entire gland. There is, however, a small and carefully selected group of patients in whom a left-sided pancreatic resection is the appropriate treatment. This subgroup is selected by imaging techniques, including CT, ERCP, or MRI outlining inflammatory complications, such as pseudocysts, fistula, and pancreatic duct stenosis, involving only (or primarily) the body and/or tail region of the pancreas. A good example is the patient who develops a mid-ductal stricture after an episode of necrotizing pancreatitis secondary to gallstone pancreatitis. Similarly, suspicion of a neoplasm or recurrent acute pancreatitis believed secondary to an isolated, mid-ductal stricture may be justification for a left-sided pancreatic resection. Overall, about 10% of all patients who undergo operative intervention for chronic pancreatitis may be candidates for a distal pancreatectomy. These distal pancreatectomies for benign disease can be performed without splenectomy, but conservation of the splenic artery and vein can be difficult and is time-consuming. Nevertheless, the advantage of avoiding the possibility of overwhelming postsplenectomy sepsis should be taken into consideration as well as the importance of the spleen for maintenance of the host defense system. Thus, preservation of the spleen is desirable if there is no clear indication for splenectomy, such as perisplenic pseudocyst or inflammatory/fibrotic encasement of the splenic vessels.
Central pancreatectomy (middle segmentectomy).
Benign lesions of the neck and proximal body of the pancreas, such as the exceedingly rare focal chronic pancreatitis or post-traumatic pancreatitis, pose an interesting operative challenge. If the lesions are not amenable to simple enucleation, surgeons may be faced with the choice of performing a right-sided resection (pancreatoduodenectomy) or a left-sided resection (distal pancreatectomy) to include the lesion, resulting in resection of a substantial amount of otherwise functioning pancreatic parenchyma. Central pancreatic resections have been reported primarily for benign or low-grade neoplasms with Roux-en-Y pancreatojejunostomy reconstruction. Central pancreatectomy affords the possibility of saving functional pancreatic tissue in attempt to avoid the complications of pancreatic insufficiency. Further studies, however, must prove the effectiveness of such an operation for patients with chronic pancreatitis. Central resections in patients with chronic pancreatitis must be viewed with caution and considered only in highly selected cases.
Pancreatic resection with islet cell autotransplantation.
Because of the concerns of pancreatic endocrine insufficiency after any pancreatic resection for chronic pancreatitis, renewed interest has focused on the possibility of performing a total pancreatectomy, isolating the islets, and reinfusing (autotransplanting) the islets into the liver. Improvements in islet cell harvesting and preservation for islet cell allotransplantation for diabetics have allowed new enthusiasm in this technique for patients with chronic pancreatitis. Results to date are encouraging, but the inability to harvest reliably an adequate number of islets and to prove successful engraftment within the liver remain current limitations. This approach may be more effective early in the disease when islets have not been depleted.
OUTCOMES
In summary, definite evidence for the best operative method for treating painful chronic pancreatitis is still not fully accepted. The study designs in the few randomized controlled trials (evidencebased Level I data) available today have some limitations in design and reporting of morbidity and include only small numbers of patients. Nevertheless, the different variations of the DPPHR, Beger, Frey, and Bern procedures appear to be as equally successful in achieving long-term pain control as pancreatoduodenectomy, but they have fewer postoperative complications and appear to be superior with regard to preservation of pancreatic function and quality of life.
Aula de Anatomia do Dr Nicolaes Tulp (1632)
O valor da obra “A Aula de Anatomia do Dr. Nicolaes Tulp” é incalculável, pois ela pertence ao acervo do Mauritshuis, em Haia, na Holanda, e é considerada uma das mais importantes e valiosas obras do museu. Além disso, a pintura é uma das mais famosas obras de Rembrandt e uma das mais importantes do período Barroco holandês. Por isso, é considerada uma obra-prima da arte ocidental e tem um valor histórico, artístico e cultural inestimável. Embora não haja um valor monetário exato para a pintura, pode-se dizer que é uma das obras mais valiosas e procuradas do mundo da arte, tanto pelo seu significado histórico quanto pela sua qualidade artística.
“A Aula de Anatomia do Dr. Nicolaes Tulp” é uma pintura a óleo sobre tela, criada por Rembrandt van Rijn em 1632. A obra mede 169,5 cm x 216,5 cm e está atualmente exposta no Mauritshuis, em Haia, na Holanda. A composição da pintura apresenta um grupo de homens em torno de uma mesa de dissecação, liderados pelo médico Nicolaes Tulp, que está realizando uma demonstração de anatomia. O corpo sendo dissecado é o de um criminoso enforcado chamado Aris Kindt. A composição apresenta uma disposição simétrica e organizada das figuras em torno da mesa, com Tulp no centro da imagem.
A luz na pintura é focada no corpo sendo dissecado, destacando-o em relação ao fundo escuro da sala. A técnica de chiaroscuro usada por Rembrandt acentua o realismo e o drama da cena. As figuras são pintadas em tons de marrom, cinza e preto, com destaques de branco. A obra apresenta detalhes precisos e realistas da anatomia do corpo, bem como das ferramentas médicas utilizadas na dissecação. O corpo do criminoso apresenta uma ferida na cabeça e uma perna amputada, o que sugere que ele pode ter sido executado por um crime violento.
No canto inferior direito da pintura, há um livro aberto com o título “Spiegel der Konst” (“Espelho da Arte”), um tratado de anatomia escrito por Adriaan van de Spiegel e utilizada pelos médicos da época. Em geral, a “Aula de Anatomia do Dr. Nicolaes Tulp” é uma obra-prima devido à sua técnica precisa e detalhada, bem como à sua habilidade em transmitir um senso de realismo e drama. A pintura é considerada uma das obras mais importantes do período Barroco holandês e é frequentemente citada como um exemplo do estilo de pintura de Rembrandt.
A seguir estão algumas das características artísticas e estéticas da obra:
- Composição: A pintura apresenta uma composição equilibrada e organizada, com as figuras dos membros da guilda cirúrgica em torno da mesa de dissecação centralizada.
- Luz e Sombra: Rembrandt usa uma técnica conhecida como chiaroscuro, ou contraste entre luz e sombra, para dar profundidade e dimensão à cena. A luz focaliza no cadáver e no médico principal, destacando-os do fundo escuro.
- Realismo: A pintura é altamente realista, mostrando detalhes precisos das ferramentas cirúrgicas, do cadáver e das expressões dos personagens.
- Cores: O uso limitado de cores em tons de marrom e cinza dá à pintura uma atmosfera austera e solene.
- Simbolismo: A pintura inclui vários elementos simbólicos, como a presença de uma coruja, que representa sabedoria, e a posição da mão do cadáver, que simboliza a morte.
- Técnica: A pintura foi executada com uma técnica de pincelada solta e fluida, que enfatiza a textura e a superfície da pintura.
Em geral, a “Aula de Anatomia do Dr. Nicolaes Tulp” é considerada uma obra-prima devido à sua habilidade técnica e sua capacidade de transmitir um senso de realismo e drama. A pintura é considerada uma das obras mais importantes do período Barroco holandês e é frequentemente citada como um exemplo do estilo de pintura de Rembrandt.
“Ao CADÁVER DESCONHECIDO, todo nosso respeito e agradecimento!”
O estudo da anatomia humana é essencial para o ensino e avanço da medicina, e o cadáver desempenha um papel fundamental nesse processo. O cadáver é uma ferramenta valiosa que permite aos estudantes de medicina, anatomia e outras áreas da saúde aprenderem sobre a estrutura e a organização do corpo humano de uma maneira muito mais eficaz do que seria possível apenas com modelos em duas dimensões ou imagens de realidade virtual.
A dissecação de um cadáver permite que os estudantes examinem as diferentes camadas de tecido e órgãos que compõem o corpo humano, geralmente ensinadas na disciplina de ANATOMIA TOPOGRÁFICA. Isso pode ajudá-los a entender como as estruturas funcionam juntas para manter a homeostase. Ao dissecar um cadáver, os estudantes podem observar as relações anatômicas entre as estruturas, entender as diferenças entre os diferentes sistemas do corpo humano e identificar as variações individuais que ocorrem em cada pessoa. Essas informações são fundamentais para o diagnóstico e o tratamento de doenças e distúrbios.
Além disso, o estudo do cadáver permite que os estudantes observem as variações normais que ocorrem no corpo humano, bem como as anomalias e patologias que podem afetar diferentes sistemas e órgãos. Isso pode ajudar os estudantes a entender as causas e os efeitos de doenças e distúrbios e a desenvolver habilidades práticas para o diagnóstico e o tratamento. Por exemplo, ao estudar um cadáver com uma patologia específica, os estudantes podem aprender a identificar essa condição em pacientes vivos e determinar o melhor tratamento para cada caso.
Além de fornecer informações valiosas sobre a estrutura do corpo humano, o estudo do cadáver também é importante para a investigação científica e o desenvolvimento de novas técnicas e tecnologias médicas. Por exemplo, ao estudar a anatomia do sistema nervoso central de um cadáver, os pesquisadores podem identificar áreas do cérebro que controlam funções específicas, como a fala ou a visão. Isso pode levar ao desenvolvimento de novas técnicas cirúrgicas que preservam essas funções durante procedimentos no cérebro.
O estudo do cadáver também é fundamental para o treinamento de cirurgiões. Através da dissecação de cadáveres, os cirurgiões podem praticar técnicas cirúrgicas complexas e aprimorar suas habilidades antes de realizar procedimentos em pacientes vivos. Isso pode ajudar a reduzir o risco de complicações durante as cirurgias e melhorar os resultados para os pacientes. A anatomia é a disciplina fundamental da formação cirúrgica desde tempos remotos na história da medicina.
No entanto, o uso de cadáveres para o estudo da anatomia humana é uma questão ética e legal complexa. Para garantir que o uso de cadáveres seja feito de forma ética e responsável, muitos países têm leis e regulamentações rigorosas que governam a dissecação de corpos humanos. Essas leis e regulamentações visam garantir que os cadáveres sejam tratados com respeito e dignidade, que o consentimento adequado seja obtido antes da dissecação e que a privacidade e a confidencialidade dos doadores sejam protegidas.
![O Cérebro, em seu curso [de pensamento]](https://scontent-dfw5-2.cdninstagram.com/v/t51.29350-15/321646926_866269021361704_9050474018765853554_n.jpg?_nc_cat=102&ccb=1-7&_nc_sid=8ae9d6&_nc_ohc=oTz5jZmm_eQAX84whEW&_nc_ht=scontent-dfw5-2.cdninstagram.com&edm=ANo9K5cEAAAA&oh=00_AfBWiKUAD1PhId65rFwjOEg_8h30do7jN6e5idq77a157g&oe=64200D8B)
The SURGEON 