IMPORTANCE:The 80-hour work-week limit for all residents was instituted in 2003 and studies looking at its effect have been mixed. Since the advent of the 16-hour mandate for postgraduate year 1 residents in July 2011, no data have been published regarding the effect of this additional work-hour restriction.OBJECTIVE:To determine whether the 16-hour intern work limit, implemented in July 2011, has adversely affected operative experience.DESIGN, SETTING, AND PARTICIPANTS:A retrospective review of categorical postgraduate year 1 Accreditation Council for Graduate Medical Education case logs from the intern class (N = 52) (with 16-hour work limit) compared with the 4 preceding years (2007-2010; N = 197) (without 16-hour work limit). A total of 249 categorical general surgery interns from 10 general surgery residency programs in the western United States were included.MAIN OUTCOMES AND MEASURES:Total, major, first-assistant, and defined-category case totals.RESULTS:As compared with the preceding 4 years, the 2011-2012 interns recorded a 25.8% decrease in total operative cases (65.9 vs 88.8, P = .005), a 31.8% decrease in major cases (54.9 vs 80.5, P < .001), and a 46.3% decrease in first-assistant cases (11.1 vs 20.7, P = .008). There were statistically significant decreases in cases within the defined categories of abdomen, endocrine, head and neck, basic laparoscopy, complex laparoscopy, pediatrics, thoracic, and soft tissue/breast surgery in the 16-hour shift intern era, whereas there was no decrease in trauma, vascular, alimentary, endoscopy, liver, and pancreas cases.CONCLUSIONS AND RELEVANCE:The 16-hour work limit for interns, implemented in July 2011, is associated with a significant decrease in categorical intern operative experience. If the 16-hour shift were to be extended to all postgraduate year levels, one can anticipate that additional years of training will be needed to maintain the same operative volume.

BACKGROUNDWe sought to determine whether US Medical Licensing Examination (USMLE) Step 1 score, American Board of Surgery (ABS) In-Training Examination (ABSITE) score, and other variables are associated with failing the ABS qualifying and certifying examinations. Identifying such factors may assist in the early implementation of an academic intervention for at-risk residents.DESIGNRetrospective review.SETTINGSeventeen general surgery training programs in the western United States.PARTICIPANTSSix hundred seven residents who graduated in 2000-2007.MAIN OUTCOME MEASURESFirst-time pass rates on the qualifying and certifying examinations, US vs non-US medical school graduation, USMLE Steps 1 and 2 scores, ABSITE scores, operative case volume, fellowship training, residency program type, and mandatory research.RESULTSThe first-time qualifying and certifying examination pass rates for the 607 graduating residents were 78% and 74%, respectively. On multivariable analysis, scoring below the 35th percentile on the ABSITE at any time during residency was associated with an increased risk of failing both examinations (odds ratio, 0.23 [95% confidence interval, 0.08-0.68] for the qualifying examination and 0.35 [0.20-0.61] for the certifying examination), as was scoring less than 200 on the USMLE Step 1 (0.36 [0.21-0.62] for the qualifying examination and 0.62 [0.42-0.93] for the certifying examination). A mandatory research year was associated with an increased likelihood of passing the certifying examination (odds ratio, 3.3 [95% confidence interval, 1.6-6.8]).CONCLUSIONSResidents who are more likely to fail the ABS qualifying and certifying examinations can be identified by a low USMLE Step 1 score and by poor performance on the ABSITE at any time during residency. These findings support the use of the USMLE Step 1 score in the surgical residency selection process and a formal academic intervention for residents who perform poorly on the ABSITE.

Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

Reid Adams Mehran Anvari Tracy Arnell Maurice Arregui Dag Arvidsson Leon Assael John Baillie Klaus Baltzers Bruce Barraclough Barbara Bass Robert Beart Jr. Kevin Behrns Michael Benninger Timothy Billiar Kevin Billingsley Martin Bjöck Charles Blanke David Bliss Cedric Bremner Michael Brunt Rudolf Bumm Joanna Cain Fabio Cappuccini Sally Carty Jorge Cervantes Howard Champion Larry Cheung Laurent Chiche Robert Cima William Cioffi David Clark Orlo Clark Alfred Cohen Kevin Conlon Michael Cotton Myriam Curet John Daly Siamak Daneshmand Merrill Dayton Edwin Deitch Kees Dejong Thomas DeLoughery Eric DeMaria Steven DeMeester Claude Deschamps Cliff Deveny Brian Diggs Douglas Dirschl John Donahue Cynthia Downard Henning Dralle Quan-Yang Duh David Easter Christopher Ellison Carlos Esquivel Jesus Esquivel S.T. Fan Doug G. Farmer Daniel Feingold Michael Fenoglio Jonathan Finks Robert Fitzgibbons Jr. Jim Fleshman David Flum Gerald Fried Andrea Frilling Eugene Fuchs Paul Gauger Keith Georgeson Bruce Gewertz Oliver Gimm Jon Gould Gene Grindlinger Jay Grosfeld Pravin Gupta Jeffrey Hagen John Ham Paul Hansen Jay Harness David Harpole Jr. Stefan Hassfeld Guo-Wei He Peter Schuyler Hedberg Max Heiland Michael Henderson Santiago Horgan William B. Inabnet George Irvin Glyn Jamieson Igal Kam Karthikeshwar Kasirajan John Kaufman Thomas Keane Keith Kelly Leena Khaitan John Kilkenny Andrew Kingsnorth Yasuhiro Kodera William Kraybill Gregory Landry Chen-hsen Lee Ari Leppäniemi Soren Laurberg Alfred Lewy Keith Lillemoe K.H. Link Michael Liptay Demetrius Litwin Chung-Yau Lo Donald Low Jim Luketich Alan Boyd Lumsden Steve Lynch Michael Mack Mike Maddaus Robert Madden T.E. Madiba David Mahvi Masatoshi Makuuchi Kamal Mansour 2005 by the Société Internationale de Chirurgie World J Surg (2005) 29: 1698–1699 Published online: 23 November 2005 DOI: 10.1007/s00268-005-2003-8

Background: Using flexible endoscopic methods, hydrogel prostheses can be safely placed, retained for long periods of time, and removed from the esophageal submucosa of pigs. This new technique may have future applications in the treatment of gastroesophageal reflux disease in selected situations. Methods: In a controlled, prospective trial, farm pigs (n = 28) or Sinclair mini-swine (n = 18) underwent sequential placements of 2–13 pliable, radio-opaque hydrogel prostheses into the submucosa of the esophagus during a single endoscopy session. A novel endoscope-overtube device was used. Followup endoscopy and/or fluoroscopy sessions were video-recorded at 6-week, 12-week, 6-month, and yearly intervals. The endoscopic removal of hydrogels was tested in vivo. Necropsy specimens were inspected for signs of chronic inflammation. Results: Overall, 98% of delivery attempts were successful (288/293). Only three hydrogels were lost after 6 weeks. Short-term animals (n = 36) retained 88% of hydrogels for periods up to 6 months. Intact hydrogels (n = 12) were easily removed from four animals at endoscopy. Long-term subjects had two or three hydrogels per animal, using either a beveled-needle device (six pigs) or a trocar design (four pigs). Trocar design: nine of nine prostheses retained at 3 years (100%). Needle design: nine of 10 prostheses retained at 3 years (90%). No significant adverse event occurred. Growth curves were similar between groups. All hydrogels remained pliable to gross inspection upon in vivo removal or necropsy. Pathology showed minimal fibrosis and no chronic inflammation. Conclusions: A novel endoscopic overtube device allows for the successful delivery of multiple hydrogel prostheses with acceptable safety and long term retention rates. These hydrogel prostheses can also be easily removed from the submucosal space of the esophagus.

PURPOSE:To determine if three-dimensional ultrasound (3D US), by nature of its ability to simultaneously evaluate structures in three orthogonal planes and to study relationships of devices to tumor(s) and surrounding anatomic structures from any desired orientation, adds significant additional information to real-time 2D US used for placement of devices for ablation of focal liver tumors.MATERIALS AND METHODS:Sixteen patients underwent focal ablation of 23 liver tumors during two intraoperative cryoablation (CA) procedures, three intraoperative radiofrequency ablation (RFA) procedures, 11 percutaneous ethanol injections (PEI) procedures, and six percutaneous RFA procedures. After satisfactory placement of the ablative device(s) with 2D US guidance, 3D US was used to reevaluate adequacy to device position. Information added by 3D US and resultant alterations in device deployment were tabulated.RESULTS:3D US added information in 20 of 22 (91%) procedures and caused the operator to readjust the number or position of ablative devices in 10 of 22 (45%) of procedures. Specifically, 3D US improved visualization and confident localization of devices in 13 of 22 (59%) procedures, detected unacceptable device placement in 10 of 22 (45%), and determined that 2D US had incorrectly predicted device orientation to a tumor in three of 22 (14%).CONCLUSIONS:Compared to conventional 2D US, 3D US provides additional relationship information for improved placement and optimal distribution of ablative agents for treatment of focal liver malignancy.

Hypothesis: Endoscopically delivered prostheses are safe, durable, and may augment a defective lower esophageal sphincter (LES).Methods: Pigs were studied as normal-LES or LES-weakened animals. A novel endoscopic delivery system was developed in order to place multiple hydrogel prostheses into the LES submucosa. Histopathology sections evaluated ultimate durability and the relationship of the prostheses to esophageal anatomy.Results: Overall, 97% of 179 prosthesis delivery attempts were successful. LES-weakened animals had LES pressures return to normal or supranormal values at 2 weeks and 2 months after prosthesis augmentation. Weakened gastric yield pressures improved to normal values at 2 weeks after prosthesis augmentation. The thickness of the muscular layers and the mucosal integrity of the esophagus was unaffected by the retained prostheses.Conclusions: Endoscopically delivered hydrogel prostheses are safe and durable. These prostheses can successfully augment a defective sphincter without recognizable damage to the esophagus. (C) 2002 Excerpta Medica, Inc. All rights reserved.

Background: The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms. Methods: Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival. Results: Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P <0.001). Of the 129 resected patients, factors significantly (P <0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendall’s tau analysis, tumor type and grade correlated significantly with all other predictors. Conclusions: Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.

SummaryThere are two methods of minimally invasive gastrostomy placement: radiologic (RG) and endoscopic (PEG). In order to investigate the effectiveness of these two methods, this study examined those patients undergoing percutaneous gastrostomy at our institution from 1 July 1993 to 30 June 1995 (44 RG, 69 PEG). Compared to PEG, RG was a shorter procedure (33.5 min vs 41.2 min) and required less conscious sedation. RG also had a higher rate of technical success (100% vs 95.7%) and a lower rate of major complications (11.4% vs 16.7%). Thirty-day mortality was similar after both procedures. These results are consistent with those from a recent meta-analysis of the literature and suggest that radiologic gastrostomy may have advantages over PEG.

We report a case of metastatic lobular breast carcinoma with extrahepatic gastrointestinal disease. On the basis of clinical findings, radiologic investigations, computerized axial tomography, gastrointestinal endoscopy, and gastric biopsy, the diagnosis of gastric and ileal Crohn's disease was made. The correct diagnosis of peritoneal carcinomatosis was made at laparoscopy. This case exemplifies the utility of laparoscopy in establishing the diagnosis and staging for abdominal disease of uncertain etiology.

PURPOSE:To evaluate the effectiveness and safety of radiologic, percutaneous endoscopic (PEG), and surgical gastrostomy.MATERIALS AND METHODS:This project involved 5,752 patients (837 patients underwent radiologic gastrotomy; 4,194, PEG; and 721, surgical gastrostomy). Seventy-two (47 male, 25 female; age range, 12-94 years) underwent gastrostomy within 1 year in this series (radiologic gastrostomy, n = 33; PEG, n = 35; surgical gastrostomy, n = 4). A meta-analysis of 5,680 additional cases from literature published from 1980 to the present was also performed.RESULTS:Rates of successful tube placement were higher for radiologic gastrostomy than for PEG in our series and in the meta-analysis (99.2% vs 95.7%, P < .001). Major complications occurred less frequently after radiologic gastrostomy in our series and in the meta-analysis (5.9% vs 9.4% for PEG and 19.9% for surgery, P < .001). Thirty-day procedure-related mortality rates were highest for surgery (2.5% vs 0.3% for radiologic gastrostomy and 0.53% for PEG, P < .001).CONCLUSION:Radiologic gastrostomy is associated with a higher success rate than is PEG and less morbidity than either PEG or surgery.

The authors describe their experience in management of bile duct injuries (n = 11), bile leaks or abscesses (n = 11), and bleeding (n = 1) as complications of laparoscopic cholecystectomy in 21 patients. Clinical presentations included jaundice, sepsis, pain, abdominal distention, and persistent gallstones. Twelve patients underwent operative cholangiography, three underwent conversion to open cholecystectomy, and 12 reoperations were performed in nine patients before interventional radiologic procedures, which included diagnostic percutaneous transhepatic cholangiography (n = 13), percutaneous biliary drainage (PBD) (n = 13), percutaneous stricture dilation (n = 3), stent insertion (n = 1), percutaneous abscess or biloma drainage (n = 19), and gallstone removal (n = 1). Each procedure was technically successful. Clinical improvement occurred in 18 of 19 patients. PBD was used as an operative guide before reconstructive surgery in two patients. Reoperation was unnecessary in 10 of 21 patients (48%). One patient died of fungal sepsis and pulmonary complications. This radiologic-surgical approach provided rapid and safe management of these complications.

We audited our recent experience with diagnostic laparoscopy performed over a 30-month period on 131 consecutive patients. Laparoscopy was 100% accurate in the diagnosis or exclusion of intra-abdominal malignant neoplasms, and future care decisions were affected by this information. Laparoscopy in the evaluation of chronic abdominal pain yielded positive findings in 47% of cases. The majority of referrals (73%) for the investigation of chronic abdominal pain came from the medical services, whereas the majority of referrals (72%) for the investigation of cancer originated from surgeons. Laparoscopy in the setting of acute abdominal pain yielded useful information that affected patient outcomes in 71% of cases. There were no serious complications in this series. Laparoscopy is a safe and useful diagnostic tool, especially for the diagnosis, staging, or exclusion of cancer.