Art-based observational training for medical students and surgical residents in two Dutch museums

Background

Art-based education is gaining interest in the medical field, particularly in specialties with a strong visual focus. Visual arts are increasingly used for the development of observational skills and social competencies. While content and objectives of art-based programs widely differ across medical faculties in the Netherlands, the diverse range of options underscore the interest in and the potential of this educational approach. In this report, we explore the value of art-based observational training for medical students and surgical residents in two prominent Dutch museums in Amsterdam and Rotterdam, respectively.

Methods

Our program, conducted at the Rijksmuseum in Amsterdam and Depot Boijmans van Beuningen Museum in Rotterdam engaged medical students (n=24) and surgeons (in training) (n=66) in an interactive workshop focused on art observation led by an experienced art-educator and a clinical professional. Learning objectives were defined and a post-workshop questionnaire was devised to evaluate participants' perceptions, with a specific focus on contribution of the program to professional development.

Results

Both residents and surgeons acknowledged that the program had a positive impact on their professional skills. The program learned them to postpone their judgements and contributed to the awareness of their personal bias. Notably, medical students believed in the program's potential contribution to their professional development. Surgeons were more critical in their evaluation, emphasizing the challenge of sustainable improvement of skills within the limited duration of the course.

Conclusions

An interactive art-based medical education program was offered to medical students, PhD students, house officers, surgical residents and surgeons in two well known Dutch museums. Participants expressed enthusiasm for the innovative educational approach they experienced at the museums. They learned about the importance of critical observation in their professional work, handling of ambiguity and got the opportunity to practice both observational and communicational skills in a creative manner. The findings indicate that medical students and surgical residents can benefit from art-based observational training, using art as a vehicle to develop their professional competencies.

Long-term outcomes after appendicectomy as experimental treatment for patients with therapy-refractory ulcerative colitis

This study assessed 25 patients with severe ulcerative colitis undergoing appendicectomy. During a median postoperative follow-up of 7.5 years, the median duration of clinical response, as observed in 15 patients, was 80 months; the median duration of endoscopic improvement, as observed in 12 of patients, was 46 months.

Missed Proximal Tracheoesophageal Fistula (TEF) in a Neonate with Type D Esophageal Atresia

We present the case of a patient with the rare type D esophageal atresia (EA), diagnosed after correction of an EA initially diagnosed as type C. Routine postoperative contrast esophagogram showed a missed proximal tracheoesophageal fistula. This case report illustrates the potential difficulties to diagnose type D EA.

Unintentional Suture Fistula Between the Proximal and Distal Esophagus in a Preterm Neonate with Type C Esophageal Atresia

We present the case of a patient with gross type C esophageal atresia in a preterm neonate (gestational age of 31 weeks + 1 day) with a birth weight of 1,470 g. The fistula was released via a thoracotomy, but no primary anastomosis could be made, due to an unexpected long gap. The distal esophagus was closed and approximated to the blind pouch using traction sutures until an adjacent position was reached. A gastrostomy was created for enteral feeding. Although a second attempt to make an anastomosis was unsuccessful, the patient unexpectedly developed a suture fistula 6 weeks after the first procedure, enabling feeding via a nasogastric tube. Over time, six dilations were necessary. Full enteral feeding was achieved at the age of 6 months. Our case confirms sparse reports that deliberately creating a suture fistula may be a solution in esophageal atresia patients when an unexpected long gap prohibits a primary anastomosis.

Erratum: Missed Proximal Tracheoesophageal Fistula (TEF) in a Neonate with Type D Esophageal Atresia

[This corrects the article DOI: 10.1055/a-2227-6389.].

Fluorescence perfusion assessment of vascular ligation during ileal pouch-anal anastomosis

BACKGROUND

Intraoperative fluorescence angiography (FA) is of potential added value during ileal pouch-anal anastomosis (IPAA), especially after vascular ligation as part of lengthening measures. In this study, time to fluorescent enhancement during FA was evaluated in patients with or without vascular ligation during IPAA.

METHODS

This is a retrospective cohort study of all consecutive patients that underwent FA-guided IPAA between August 2018 and December 2019 in our tertiary referral centre. Vascular ligation was defined as disruption of the ileocolic arcade or ligation of interconnecting terminal ileal branches. FA was performed before and after ileoanal anastomotic reconstruction. During FA, time to fluorescent enhancement was recorded at different sites of the pouch.

RESULTS

Thirty-eight patients [55.3% male, median age 45 years (IQR 24-51 years)] were included, of whom the majority (89.5%) underwent a modified-2-stage restorative proctocolectomy. Vascular ligation was performed in 15 patients (39.5%), and concerned central ligation of the ileocolic arcade in 3 cases, interconnecting branches in 10, and a combination in 2. For the entire cohort, time between indocyanine green (ICG) injection and first fluorescent signal in the pouch was 20 s (IQR 15-31 s) before and 25 s (IQR 20-36 s) after anal anastomotic reconstruction. Time from ICG injection to the first fluorescent signal at the inlet, anvil and blind loop of the pouch were non-significantly prolonged in patients that received vascular ligation.

CONCLUSIONS

Results from this study indicate that time to fluorescence enhancement during FA might be prolonged due to arterial rerouting through the arcade or venous outflow obstruction in case of vascular ligation.

Intestinal ultrasound detects an increased diameter and submucosal layer thickness in the appendix of patients with ulcerative colitis compared to healthy controls - a prospective cohort study

BACKGROUND

Increasing evidence suggests that appendicectomy as alternative treatment for ulcerative colitis (UC), especially in patients with histopathological appendiceal inflammation. Intestinal ultrasound (IUS) is a non-invasive diagnostic modality to characterise appendiceal inflammation.

AIMS

To assess appendiceal IUS characteristics in UC patients and compare findings to healthy controls (HC).

METHODS

In this prospective study, appendiceal IUS was performed in consecutive UC patients with active (A; n = 35) or quiescent (Q; n = 30) disease and in HC (n = 30). Transverse appendiceal diameter (TAD) and additional IUS parameters (bowel wall thickness, submucosal layer thickness and colour Doppler signal) were assessed.

RESULTS

The appendix was visualised in 41/65 UC patients (63.1%; A vs. Q: 23/35 vs. 18/30, p = 0.67) and 18/30 (60%) HC. UC patients had a higher TAD (A: 5.5 mm, Q: 5.0 mm, HC: 4.3 mm; A-HC p < 0.01; Q-HC p = 0.01, A-Q p = ns) and submucosal layer thickness (A: 1.0 mm, Q: 1.0 mm, HC: 0.7 mm; A-HC p < 0.01, Q-HC: p = 0.01, A-Q: p = ns) when compared to HC. A TAD ≥6 mm corresponding to an ultrasonographic suspicion of acute appendicitis was mainly reported in A-UC patients (A: 43%; Q: 6%; HC: 0%, p = 0.01) and occurred irrespective of disease extent. However, none of the patients had a clinical suspicion of acute appendicitis.

CONCLUSION

A TAD ≥6 mm was predominantly seen in A-UC. TAD was higher in UC patients compared to HC irrespective of disease activity and was characterised by an increased submucosal layer thickness. IUS therefore has the potential to identify UC patients with appendiceal inflammation.

Clinical relevance of endoscopic peri-appendiceal red patch in ulcerative colitis patients

BACKGROUND

Increasing evidence is suggesting appendectomy as an alternative treatment for ulcerative colitis (UC), especially in case of histological appendiceal inflammation. Therefore, preoperative identification of appendiceal inflammation could be beneficial. This study aimed to assess the prevalence of peri-appendiceal red patch (PARP) on colonoscopy. In addition, prognostic relevance of PARP for disease course and its predictive value for histological appendiceal inflammation in patients undergoing appendectomy was assessed.

METHODS

UC patients undergoing colonoscopy in 2014/2015 were included to determine PARP-prevalence in a cross-sectional study. Findings were correlated to patient and disease characteristics, upscaling of treatment and colectomy rates after cross-sectional colonoscopy. In patients undergoing appendiceal resection, histopathological inflammation was assessed using the Robarts Histopathology Index (RHI).

RESULTS

In total, 249 patients were included of which 17.7% (44/249) had a PARP. Patients with PARP were significantly younger with a shorter disease course. The majority of patients with PARP (61.4%) was in endoscopic remission. Patients with PARP required more upscaling of medical therapy (81.8% vs. 58.0%, p < 0.01), and more PARP patients underwent colectomy (13.6% vs. 4.9%, p = 0.04). Patients with PARP had a higher median RHI in resection specimens (14 vs. 7, p < 0.01).

CONCLUSION

PARP was present during colonoscopy regardless disease activity and was predominantly found in UC patients with younger age and shorter disease duration. PARP patients had a more severe course of UC, and in case of appendectomy, more severe histopathological appendiceal inflammation. Appendectomy as an experimental therapy for UC has been suggested to be predominantly effective in UC patients with appendiceal inflammation. This study demonstrates that presence of a PARP on colonoscopy predicts appendiceal inflammation. After consensus has been reached on the therapeutic effect of appendectomy, assessing PARP presence during colonoscopy could therefore contribute to identifying patients most likely to respond.

Incidence and causes of failure in various anatomical pouch designs 20 years after surgical primary ileal-pouch anal anastomosis construction

PURPOSE

Since the introduction of ileo-pouch anal anastomosis (IPAA) surgery, various pouch designs have been applied. Recently, there has been renewed interest in creating larger pouch designs to reduce defecation frequency after pouch surgery. The aim of this study was to assess chronic pouch failure (PF) rates and causes in alternative S or septated (SP) pouches when compared to J pouches and B- shaped adaptations.

METHODS

This retrospective cohort study included patients that underwent primary IPAA construction surgery from 1978-2000. Pouch designs were subdivided in J and B (J/B), and larger pouches (S/SP). PF included need for a pouch excision, redo pouch procedure, revisional pouch surgery, or permanent ileostomy surgery. Outcomes of this study were incidence and causes for PF per pouch design group.

RESULTS

Out of 200 patients who underwent IPAA surgery, 19 had an S/SP design and 181 had a J/B design. After a follow-up of 27.0 (IQR 23.3 - 29.0) years, 45/200 (22.5%) patients who underwent IPAA surgery between 1975-2000 developed PF. Some 78.9% of patients with an S/SP pouch developed PF, compared to 16.7% of patients with a J/B pouch (p < 0.01). Mechanical outlet issues occurred more often in S/SP pouches when compared to J/B (42.1% vs. 1.1%, p < 0.01), and were predominantly caused by septal- or pouch wall intussusception and efferent loop kinking (S-pouch).

CONCLUSION

Despite an inevitable proportion of bias, the current study revealed that S/SP pouches were characterized by an increased PF incidence due to emptying problems after long-term follow-up when compared to J/B pouches. Constructing an S pouch or large septated reservoir at index surgery should therefore be questioned because of a shorter longevity.

Ileal Pouch-anal Anastomosis Complications and Pouch Failure: A systematic review and meta-analysis

Objective

This systematic review aims to assess the incidence of pouch failure and the correlation between ileal pouch-anal anastomosis (IPAA)-related complications and pouch failure.

Background

Previous studies demonstrated wide variation in postoperative complication rates following IPAA.

Methods

A systematic review was performed by searching the MEDLINE, EMBASE, and Cochrane Library databases for studies reporting on pouch failure published from January 1, 2010, to May 6, 2020. A meta-analysis was performed using a random-effects model, and the relationship between pouch-related complications and pouch failure was assessed using Spearman's correlations.

Results

Thirty studies comprising 22,978 patients were included. Included studies contained heterogenic patient populations, different procedural stages, varying definitions for IPAA-related complications, and different follow-up periods. The pooled pouch failure rate was 7.7% (95% confidence intervals: 5.56-10.59) and 10.3% (95% confidence intervals: 7.24-14.30) for studies with a median follow-up of ≥5 and ≥10 years, respectively. Observed IPAA-related complications were anastomotic leakage (1-17%), pelvic sepsis (2-18%), fistula (1-30%), stricture (1-34%), pouchitis (11-61%), and Crohn's disease of the pouch (0-18%). Pelvic sepsis (r = 0.51, P < 0.05) and fistula (r = 0.63, P < 0.01) were correlated with pouch failure. A sensitivity analysis including studies with a median follow-up of ≥5 years indicated that only fistula was significantly correlated with pouch failure (r = 0.77, P < 0.01).

Conclusions

The single long-term determinant of pouch failure was pouch fistula, which is a manifestation of a chronic leak. Therefore, all effort should be taken to prevent an acute leak from becoming a chronic leak by early diagnosis and proactive management of the leak.

Mini abstract

This systematic review aims to assess the incidence of pouch failure and the correlation between IPAA-related complications and pouch failure. Long-term pouch failure was correlated with fistula, suggesting that early septic complications may result in fistula formation during long-term follow-up, leading to an increased risk of pouch failure.

Endo-sponge Assisted Early Surgical Closure of Ileal Pouch-anal Anastomotic Leakage Preserves Long-term Function: A Cohort Study

BACKGROUND AND AIMS

Endo-sponge [Braun Medical] assisted early surgical closure [ESC] is an effective treatment to control pelvic sepsis after ileal pouch-anal anastomosis [IPAA] leakage, and became standard treatment in our centre from 2010 onwards. The aim of this cohort study was to assess the long-term pouch function of ulcerative colitis [UC] patients treated with ESC or conventional management [CM] for anastomotic leakage after IPAA.

METHODS

Consecutive patients who underwent an IPAA for UC between 2002 and 2017 were included. Patients treated with ESC [2010-2017] or CM [2002-2009] for anastomotic leakage were compared with control patients without anastomotic leakage of the corresponding time period. Main endpoints were long-term pouch function on a 3-point scale and pouch failure, as measured with the validated pouch dysfunction score questionnaire.

RESULTS

Some 280 of 334 patients [84%] returned the pouch dysfunction questionnaire, of whom 18 were treated with ESC and 22 with CM for anastomotic leakage. Control cohorts included 133 [2010-2017] and 107 patients [2002-2009]. Between ESC-treated patients and control patients, pouch function [p = 0.647] and pouch failure rates [0/18 versus 5/133, p >0.99] were similar. CM resulted in worse pouch function [p = 0.016] and a higher pouch failure rate [5/22 versus 5/107, p = 0.013] compared with control patients.

CONCLUSIONS

ESC, in contrast to CM, for IPAA leakage in UC patients is associated with preservation of pouch function and preclusion of pouch failure, probably due to early and effective treatment of pelvic sepsis.