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The lack of standardized skill training reported by medical students in performing tube thoracostomies may be associated with higher complications. The ideal training model is yet to be determined. This study sought to evaluate three different models.Between 2015 and 2017, 204 last-year medical students of Universidade de São Paulo with no prior training in tube thoracostomy were randomized into three groups: cadaver, pig, and synthetic models. All groups performed 1-d tube thoracostomy hands-on training and a 40-min theoretical class. The knowledge acquisition was measured by a comparison between a theoretical test before and 3 wk after the class, and the skills improvement was evaluated by a comparison between the skills test on the same day of the hands-on training and another after 24 wk (the retention skill test). A questionnaire was submitted to evaluate their satisfaction rate and self-reported confidence, as per a Likert scale.The theoretical post-test score was higher compared to the pretest score in all groups (P 0.001). The retention skills test in the cadaver and synthetic groups decreased compared to the skills test (P = 0.01 and P = 0.007, respectively). There was no difference between the groups either in the theoretical test or in the skills test. Student satisfaction was higher in the cadaver and pig groups. The confidence perception increased in all groups after the training.The models used for tube thoracostomy training appear to have a similar impact on skills retention, knowledge acquisition, and confidence. Although the satisfaction rate is lower for the synthetic model, it has no biological risk or ethical issues and is more feasible.

Introduction: Preoperative education helps patients feel less anxious and improve self-care while decreasing hospitalization time and demand for postoperative analgesia. Health literacy, culture and language play vital roles in patients’ understanding of health issues and may influence treatment outcomes. Obstacles are more evident in low- and middle-income countries (LMICs), where inadequate patient education levels are higher and hospital resources lower. Methodology: A prospective pilot study assessing the feasibility of online preoperative multimedia animations as guides for surgical patients in an LMIC was performed. They are in the local language with a holistic focus on surgical patient education. Patients admitted to a public hospital in Brazil for acute cholecystitis or appendicitis were included. Feasibility was represented by acceptability rate and ease of integration with department protocols. Results: Thirty-four patients were included in the study. Twenty-six patients concluded the intervention (acceptability rate of 76.5%). Demographic factors seemed to affect results, indicated by higher acceptability from those with lower education levels, from younger patients and from women. No issues were reported regarding integration to local protocols. Discussion: Few studies have evaluated use of multimedia resources for preoperative patients. No studies assessed the use of animations and none analyzed digital patient education resources in an LMIC. This study demonstrated that the use of animations for patient education in LMICs is feasible. A step-based protocol approach is proposed by this study to aid the implementation of patient education digital interventions. Conclusion: The use of online multimedia animations in local language as preoperative guides in LMICs is feasible. It may help improve patient education in these contexts and promote beneficial clinical outcomes for surgical patients. This positive feasibility study opens the way for future randomized trials to assess the tool’s clinical impacts. Funding: None to declare. Declaration of Interest: Gabriel Schnitman is an intern for Mitacs Accelerate program. No other conflicts of interest to declare. Ethical Approval: This study was approved by the Institutional Review Board at McGill University in Canada and in the Research Ethics Board in the University of Sao Paulo (USP) in Brazil, where certificates of ethical approval were obtained.

Highlights • A complex pancreatic trauma successfully managed with surgical approaches at three different times. • Performance of three different times treatment for a complex pancreatic trauma. • Proposal of management of complex pancreatic trauma in clinically unstable patients., Introduction Severe injuries of the pancreatic head and duodenum in haemodynamically unstable patients are complex management. The purpose of this study is to report a case of complex pancreatic trauma induced by gunshot and managed with surgical approaches at three different times. Presentation of case Exploratory laparotomy was indicated after initial emergency room care, with findings of cloudy blood-tinged fluid and blood clots on the mesentery near the hepatic angle, on the region of the 2nd portion of the duodenum and at the pancreatic head. Gastroduodenopancreatectomy was performed with right hemicolectomy and the peritoneal cavity was temporarily closed by a vacuum peritoneostomy. Surgical reopening occurred on the fifth postoperative day, and the patient was subjected to single-loop reconstruction of the intestinal transit with telescoping pancreaticojejunal anastomosis, biliodigestive anastomosis with termino-lateral hepaticojejunal anastomosis with a Kehr drain and gastroenteroanastomosis in 2 planes. The terminal ileostomy was maintained. After 2 days, the patient was subjected to abdominal wall closure without complications, which required relaxing Gibson incisions and wound closure with polypropylene mesh placement in a pre-aponeurotic position closed with multiple stitches. Results The patient was discharged on the 40th post-trauma day without drains, with a functioning ileostomy and with a scheduled reconstruction of intestinal transit. Conclusion In the presence of multiple associated injuries, hemodynamic instability and the need for an extensive surgical procedure such as duodenopancreatectomy, damage control surgery performed in stages as reported here enables the clinical stabilization of the patient for definitive treatment, achieving better survival results.

Highlights • Desmoid type fibromatosis, although benign and rare tumors, pose significant challenge to surgeons due to their high morbidity and recurrence rate. • After radical resection, closure of the abdominal wall defect requires the surgeońs expertise and an accurate technique. • Primary abdominal wall reconstruction using onlay mesh achieves high closure rate and low risk of significant complications., Background Abdominal wall desmoid type fibromatosis management has been changing over recent years, from an aggressive approach towards a more conservative one. When radical resection is indicated, the surgical team faces the challenge of abdominal wall reconstruction, for which optimal technique is still debated. The present study reports the experience from a single center with abdominal closures after desmoid type fibromatosis resection. Material and Methods Retrospective analysis of patients who underwent abdominal wall closure after sporadic abdominal desmoid type fibromatosis radical resection from 1982 to 2013. Results Twenty-seven patients were included, mean tumor diameter was 10 + 5.3 cm, and the main choice of abdominal wall reconstruction was midline closure with anterior rectus sheath relaxing incisions and polypropylene onlay mesh (74% of the cases). Only 7% of the cases required more complex procedures for skin closure. Mean follow-up was 5 years and 89% remained disease-free. No grade 4 or 5 complications were observed. Conclusion High midline fascial closure rate can be achieved after resection of abdominal wall desmoid tumor using relaxing incisions and mesh, with low complication rate.

INTRODUCTION Fistuloclysis is an alternative method for enteral nutrition infusion, and has been successfully employed for the management of patients with high output small bowel fistula. However it has some deficiencies also. PRESENTATION OF CASE A 42-year-old woman with multiple high output enterocutaneous fistula was submitted to fistuloclysis with reinfusion of chyme, after a period of several complications due to parenteral nutrition. DISCUSSION Enteral nutrition provide better nutrition and fewer complications than parenteral nutrition. The enterocutaneous fistula usually does not allow enteral nutrition, however the use of fystuloclysis can fix this issue. The reinfusion of chyme provide the possibility of oral intake and better control of hydroeletrolitics disorders. CONCLUSION More studies on the physiological effects of the chyme recirculation could add more data contributing to the clarification of this complex issue, but we believe that patients with high output and very proximal enterocutaneous fistula can be sucessfully treated with fistuloclysis and recirculation of chyme.