Over Worked and Under Paid: How Resident Finances Impact Perceived Stress, Career Choices, and Family Life.

BACKGROUND: The magnitude of student debt plaguing our nation is a major topic in political and academic spheres with median medical student debt of $200,000. This is compounded by poor financial health during training. This study evaluates how debt and financial wellness influence resident perceived stress, mental health, career plans, and relationships. METHODS: General surgery trainees at an academic institution were surveyed regarding financial parameters, perceived stress, and the impact of finances on their career and family life. A validated stress assessment instrument, the Perceived Stress Scale, was used to evaluate trainee stress. The median perceived stress score was compared for groups using a Wilcoxon rank-sum test. RESULTS: Fifty-eight (61% response rate) residents responded to the survey. The median (range) student loan debt was $200,000-500,000 ($0-750,000) and savings was $5000-10,000 ($0-20,000+). 18 (31%) trainees had monthly credit card debt. Half of the respondents did not have enough liquid assets for an emergency fund, defined as 3 mo of living expenses. The median perceived stress score was 16 (1-30) or moderate stress. Perceived stress score was significantly associated with the trainee's response to how finances impacted their future career choice, practice style, and relationships (P < 0.005 for all). However, the perceived stress score was not associated with objective measures of financial wellness, such as the overall level of medical school debt, savings, or having an emergency fund. DISCUSSION: The trainee's subjective perception of financial wellness, rather than objective financial parameters was associated with higher levels of perceived stress, the strain on relationships, and a greater impact on future practice styles. The majority of surgery residents did not have enough liquid assets for an emergency fund, independent of the level of debt, which emphasizes how financially leveraged residents are during training. Although burnout during surgical training is multifactorial, formal financial education incorporated into graduate medical education programs could increase financial literacy, help to mitigate financial risk, and ultimately decrease some of the perceived stress residents possess.

Anal Intraepithelial Neoplasia Screening With Anal Pap Tests: Follow-up and Corresponding Histology.

BACKGROUND: Anal cytology is used as a screening tool in the detection of precancerous anal squamous lesions. Follow-up clinical examination after abnormal anal cytology is recommended. The objective of this study was to determine how often abnormal cytology was followed by a clinical examination at our institution and how often cytology predicted histologic outcome. MATERIALS AND METHODS: A retrospective chart review was performed (2008-2018) on patients with anal cytology, demonstrating either low-grade or high-grade squamous intraepithelial lesion. Clinical examination within 1 y (digital rectal examination, anoscopy, or high-resolution anoscopy) was recorded. The probability of anal intraepithelial neoplasm on biopsy after dysplasia on cytology was calculated, and McNemar's test was used to determine if there was correspondence between cytology and histology. RESULTS: A total of 327 anal cytology results demonstrated dysplasia (75% low grade and 25% high grade) in 182 patients. Seventy-five percent of dysplastic anal cytology were followed by clinical examination within 1 y, and 50% were biopsied. The probability of dysplasia on histology after dysplasia on cytology was 72% (95% confidence interval: 64%-78.5%). Twenty-eight percent of low-grade cytology results were upgraded to advanced disease (high-grade or invasive cancer) on histology. A low-grade cytology result was unable to preclude high-grade histology in our population. CONCLUSIONS: There is room for improvement at our institution to consistently follow-up with clinical examination after abnormal anal cytology. Our data suggest this is especially important considering anal cytology is an imperfect predictor of histologic anal intraepithelial neoplasia and invasive disease. Clinical examination is a critical component of anal dysplasia screening and follow-up.

Does Anastomotic Leak Contribute to High Failure-to-rescue Rates?

OBJECTIVE: Our aim was to evaluate failure-to-rescue (FTR) after anastomotic leak (AL) in colectomy patients. BACKGROUND: In the era of pay for performance, it is imperative that we understand the quality measures under which we are scrutinized. FTR has been proposed as a marker of surgical quality. We investigated the role of complications in FTR rates in colectomy patients. METHODS: Patients who underwent nonemergent colectomy from 2012 to 2013 were identified from the The American College of Surgeons National Quality Improvement Program (ACS NSQIP database). Mortality after AL was assessed and stratified in relation to mortality after other postoperative complications. χ and logistic regression analysis were used to assess the effect of AL on mortality. RESULTS: We identified 30,101 patients who met inclusion criteria, 1127 suffered an AL (3.7%). FTR was increased in patients with AL compared with those without AL (6% vs 1%, P < 0.001). The mortality rate after leak was similar to mortality after other major complications. Independent risk factors for death after AL included older age (odds ratio [OR] 3.140; 95% confidence interval [CI], 1.744-5.651), cancer diagnosis (OR 2.032; 95% CI, 1.177-3.507), and open approach (OR 2.124; 95% CI, 1.194-3.776) while preoperative bowel preparation was protective (OR 0.563; 95% CI, 0.328-0.969). CONCLUSIONS: AL is a common complication after colectomy with a relatively high FTR rate. As hospitals are penalized for not reaching specific rates of FTR, we must better understand these complex relationships to improve quality and safety of patient care.

Short-term outcomes of minimally invasive versus open colectomy for colon cancer.

BACKGROUND: Laparoscopic and open approaches to colon resection have equivalent long-term outcomes and oncologic integrity for the treatment of colon cancer. Differences in short-term outcomes should therefore help to guide surgeons in their choice of operation. We hypothesized that minimally invasive colectomy is associated with superior short-term outcomes compared to traditional open colectomy in the setting of colon cancer. MATERIALS AND METHODS: Patients undergoing nonemergent colectomy for colon cancer in 2012 and 2013 were selected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) targeted colectomy participant use file. Patients were divided into two cohorts based on operative approach-open versus minimally invasive surgery (MIS). Univariate, multivariate, and propensity-adjusted multivariate analyses were performed to compare postoperative outcomes between the two groups. RESULTS: A total of 11,031 patients were identified for inclusion in the study, with an overall MIS rate of 65.3% (n = 7200). On both univariate and multivariate analysis, MIS approach was associated with fewer postoperative complications and lower mortality. In the risk-adjusted multivariate analysis, MIS approach was associated with an odds ratio of 0.598 for any postoperative morbidity compared to open (P < 0.001). CONCLUSIONS: This retrospective study of patients undergoing colectomy for colon cancer demonstrates significantly improved outcomes associated with a MIS approach, even when controlling for baseline differences in illness severity. When feasible, minimally invasive colectomy should be considered gold standard for the surgical treatment of colon cancer.

Postoperative complications in patients with rectal cancer are associated with delays in chemotherapy that lead to worse disease-free and overall survival.

OBJECTIVE: The objective of this study was to identify the risk factors for delays in chemotherapy after rectal cancer surgery and evaluate the effects of delayed therapy on long-term outcomes. We also sought to clarify what time frame should be used to define delayed adjuvant chemotherapy. BACKGROUND: Postoperative complications have been found to influence the timing of chemotherapy in patients with colon cancer. Delays in chemotherapy have been shown to be associated with worse overall and disease-free survival in patients with colorectal cancer, although the timing of delay has not been agreed upon in the literature. STUDY DESIGN: We performed a retrospective review of a prospectively maintained rectal cancer database. Univariate analysis was used to identify risk factors for delayed chemotherapy. Kaplan-Meier curves were generated to compare overall and disease-free survival in patients based on complications and timing of chemotherapy. SETTINGS: This study was performed at the University of Wisconsin Hospital, Madison, Wisconsin, between 1995 and 2012. PATIENTS: Patients with rectal cancer who underwent proctectomy with curative intent were included in this study. OUTCOME MEASURES: Timing of chemotherapy, 30-day complications, and 30-day readmissions were the main outcome measures. RESULTS: Postoperative complications and 30-day readmissions were associated with delays in chemotherapy ≥8 weeks after surgery. Patients who received chemotherapy ≥8 weeks postoperatively were found to have worse local and distant recurrence rates and worse overall survival in comparison with patients who received chemotherapy within 8 weeks of surgery. LIMITATIONS: The limitations of this study include its retrospective nature and that it was performed at a single institution. CONCLUSIONS: We found complications and readmissions to be risk factors for delayed chemotherapy. Patients who received therapy ≥8 weeks postoperatively had worse disease-free and overall survival.

Medically Smart, Fiscally Illiterate: Lack of Financial Education Leads to Poor Retirement Savings Strategies in Surgical Trainees.

INTRODUCTION: Resident physicians are uniquely at high financial risk given their long training programs, lack of financial education, and documented poor financial literacy. Budgeting for retirement savings is an important metric for financial literacy. METHODS: Semi-structured interviews were conducted with residents from two distinct surgery programs to assess their current financial status and their knowledge of and attitudes toward retirement savings strategies. Qualitative analysis was performed and the themes identified were examined in the context of previously reported quantitative survey data. RESULTS: As previously reported, 105 residents at Site 1 completed a comprehensive financial survey 56% of respondents reported having no retirement savings. On additional analysis, only 26% residents surveyed reported optimal savings habits defined as contributing $5000/year to a retirement account starting their first year of training. 23 residents from both sites and representing all post-graduate-year (PGY) levels then participated in the focused, semi-structured interviews. Site 2 residents were less likely to be female (P = .02) and carried a significantly larger debt burden (p < .01) but were otherwise comparable to residents from Site 1. On qualitative analysis three consistent themes emerged: (1) Resident understanding of strategies for retirement savings is poor; (2) Lack of knowledge is the primary barrier; (3) Surgical residents desire financial education. CONCLUSIONS: Surgery residents have a large debt burden, minimal retirement savings and an overall lack of understanding of savings strategies. Well-designed, early, and accessible educational interventions may improve the "financial vital signs" of surgical trainees and establish habits for long-term financial success.

Visceral obesity is associated with outcomes of total mesorectal excision for rectal adenocarcinoma.

BACKGROUND AND OBJECTIVES: General obesity, measured by the body mass index (BMI), increases the technical difficulty of total mesorectal excision (TME) but does not affect oncologic outcomes. The purpose of this study is to compare visceral and general obesity as predictors of outcomes of TME for rectal adenocarcinoma. METHODS: Adult patients undergoing TME for rectal adenocarcinoma were retrospectively identified. Preoperative computed tomography scans were used to measure abdominal circumference (AC), visceral (VFA), and subcutaneous fat area (SFA). BMI, AC, VFA, SFA, total fat area (TFA, sum of VFA and SFA), and VFA/SFA ratio were examined for association with operative, postoperative, oncologic, and survival outcomes in a univariate analysis model. RESULTS: Between 1999 and 2009, 113 patients met inclusion criteria. Increasing VFA and VFA/SFA ratio were associated with reduced lymph node retrieval (P = 0.03 and P = 0.009, respectively). The association between increasing VFA/SFA ratio with delayed resumption of oral intake (P = 0.05) and prolonged overall survival (P = 0.003) were also significant. Increasing BMI was associated with improved overall (P = 0.02) but not disease-free survival (P = 0.14). CONCLUSION: Visceral obesity, measured by VFA/SFA ratio, is a better predictor of postoperative, oncologic, and survival outcomes after TME for rectal adenocarcinoma than general obesity measured by the BMI.

Comparable postoperative morbidity and mortality after laparoscopic and open emergent restorative colectomy: outcomes from the ACS NSQIP.

BACKGROUND: Laparoscopic surgery is safe and effective in the management of common abdominal emergencies. However, there is currently a lack of data about its use for emergency colorectal surgery. We hypothesized that laparoscopy can improve the postoperative outcomes of emergency restorative colon resection. METHODS: Adult patients undergoing emergent open and laparoscopic colon resection with primary anastomosis were retrieved from the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2008 inclusive. Demographic and operative characteristics, laboratory values, and postoperative outcomes were compared between patients undergoing laparoscopic and open colon resection using univariate analyses, multivariate logistic regression, and propensity score analyses. RESULTS: A total of 341 laparoscopic (9.6 %) and 3211 (90.4 %) open colon resections were included. Patients undergoing laparoscopic surgery had a significantly lower prevalence of co-morbidities and better postoperative outcomes. On multivariate analysis, laparoscopic surgery was an independent predictor of a longer operating time (p < 0.001) and shorter total (p = 0.013) and postoperative (p = 0.004) hospital stays, but it did not affect the need for intraoperative blood transfusion (p = 0.488), the 30-day reoperation rates (p = 0.969), or mortality (p = 0.417). After adjusted propensity score analysis, postoperative morbidity (p = 0.833) and mortality (p = 0.568) were comparable in patients undergoing laparoscopic and open surgery. CONCLUSIONS: On a national scale, laparoscopic emergent colon resections are being performed in a small number of patients, who have favorable co-morbidity characteristics and improved postoperative outcomes. Laparoscopic emergent colon resection with primary anastomosis has postoperative morbidity and mortality rates comparable to those seen with the open approach, and it reduces the total and postoperative length of hospital stay.

Laparoscopy improves short-term outcomes after surgery for diverticular disease.

BACKGROUND & AIMS: Observational studies and small randomized controlled trials have shown that the use of laparoscopy in colon resection for diverticular disease is feasible and results in fewer complications. We analyzed data from a large, prospectively maintained, multicenter database (National Surgical Quality Initiative Program) to determine whether the use of laparoscopy in the elective treatment of diverticular disease decreases rates of complications compared with open surgery, independent of preoperative comorbid factors. METHODS: The analysis included data from 6970 patients who underwent elective surgeries for diverticular disease from 2005 to 2008. Patients with diverticular disease were identified by International Classification of Diseases, 9th revision codes and then categorized into open or laparoscopic groups based on Current Procedural Terminology codes. Preoperative, intraoperative, and postoperative data were analyzed to determine factors associated with increased risk for postoperative complications. RESULTS: Data were analyzed from 3468 patients who underwent open surgery and 3502 patients who underwent laparoscopic procedures. After correcting for probability of morbidity, American Society of Anesthesiology class, and ostomy creation, overall complications (including superficial surgical site infections, deep incisional surgical site infections, sepsis, and septic shock) occurred with significantly lower incidence among patients who underwent laparoscopic procedures compared with those who received open operations. CONCLUSIONS: The use of laparoscopy for treating diverticular disease, in the absence of absolute contraindications, results in fewer postoperative complications compared with open surgery.

The Optimal Ileal Pouch: Physiologic Parameters Significantly Correlate with Overall Pouch Function.

BACKGROUND: Ileal pouch function is affected by several patient factors and pouch physiology. The significance of pouch physiology on optimal pouch function has not been well characterized. The purpose of this study was to examine specific post-ileal pouch anal anastomosis (IPAA) physiologic parameters to determine impact on pouch function and quality of life. METHODS: Patients undergoing proctocolectomy with IPAA for ulcerative colitis were examined. Post-IPAA compliance, pouch anal pressure gradient (PAPG), and function were assessed 6-8 months postoperatively. Compliance was calculated as change in volume divided by change in pressure. PAPG was calculated as the difference between anal pressure and intra-pouch pressure at a fixed volume. Pouch function evaluation included stool frequency and episodes of incontinence. Quality of life was evaluated using the Rockwood Fecal Incontinence Quality of Life Scale. RESULTS: A total of 125 patients were investigated. Post-IPAA resting anal pressure averaged 58.1 ± 15 mmHg. Mean volume and intra-pouch pressure at evacuation were 245 mL and 33.9 mmHg, respectively. Compliance averaged 11.2 mmHg/mL with a mean PAPG of - 29.3 mmHg. Compliance and PAPG correlated with 24-h (p = 0.003, p = 0.004) and nighttime stool frequency (p = 0.04, p = 0.03). Daytime continence was impacted by compliance (p = 0.04), PAPG (p = 0.02), and resting anal pressure (p = 0.02). CONCLUSION: This unique evaluation reveals a significant correlation between IPAA physiologic properties and function. Optimal function and quality of life depend in part on maintaining optimal pouch compliance and pressure differentials between the pouch and anal canal, defined by the pouch anal pressure gradient.

Body mass index does not affect postoperative morbidity and oncologic outcomes of total mesorectal excision for rectal adenocarcinoma.

INTRODUCTION: Obesity adds to the technical difficulty of colorectal surgery and is a risk factor for postoperative complications. We hypothesized that obese patients have increased morbidity and poor oncologic outcomes after proctectomy for rectal adenocarcinoma. METHODS: Adult patients undergoing total mesorectal excision (TME) for rectal adenocarcinoma at a tertiary referral center were retrospectively identified from a prospectively maintained database. Operative characteristics, postoperative complication rates, and oncologic outcomes were compared in patients with BMI > or = 30 kg/m(2) and BMI < 30 kg/m(2). RESULTS: Between 1997 and 2009, 254 patients underwent proctectomy for rectal adenocarcinoma, of whom 27% were obese. There were no significant differences in demographics, comorbidities or preoperative oncologic characteristics between obese and nonobese groups. Patients with BMI > or = 30 kg/m(2) had longer operative times (p = 0.04) and higher intraoperative blood loss (p < 0.001) but comparable postoperative complication rates (p = 0.80), number of lymph nodes retrieved (p = 0.57), margin-negative resections (p = 0.44), and disease-free survival (p = 0.11). Obese patients had longer overall survival (p = 0.05). Tumor stage was the only variable associated with disease-free (p < 0.001) and overall survival (p < 0.001). CONCLUSION: Despite increased technical difficulty of resection, obesity does not increase the risk of postoperative morbidity or adversely affect oncologic outcomes after total mesorectal excision of rectal adenocarcinoma.

Laparoscopy decreases postoperative complication rates after abdominal colectomy: results from the national surgical quality improvement program.

OBJECTIVE: Compare outcomes of non-emergent laparoscopic to open colon surgery. BACKGROUND: Laparoscopy has revolutionized much of gastrointestinal surgery. Colon and rectal surgery has seen drastic changes with many of the abdominal operations being performed laparoscopically. However, data comparing recovery and complications in patients undergoing laparoscopic and open colon surgery has shown only slight benefits for laparoscopy. Given the large benefits of laparoscopy in most gastrointestinal surgical procedures, this outcome is surprising. We, therefore, have set out to test the hypothesis that laparoscopic approaches decreases postoperative complications. METHODS: We have undertaken a review of the database maintained by the American College of Surgeon's National Surgical Quality Improvement Program. We have identified 8660 patients who met inclusion criteria for this study. Postoperative complication data were collected for patients undergoing laparoscopic or open colon surgery. Using a combination of univariate and multivariate analyses we evaluated for statistical significance. RESULTS: We found that laparoscopy decreased overall complications as well as individual complications. We found a decreased length of stay as well as a decreased risk for postoperative complications in the elderly. We found that laparoscopy decreased complication rate independent of the probability of morbidity statistic. CONCLUSIONS: When controlled for probability of morbidity, laparoscopy decreases the rate of postoperative complications. Given the equivalent outcomes of laparoscopic approaches, we conclude that laparoscopy should be offered to all patients who lack an absolute contraindication for laparoscopic surgery.

Bleeding stomal varices: case series and systematic review of the literature.

BACKGROUND & AIMS: Bleeding stomal varices are a common problem in patients with surgical stomas and portal hypertension, and remain difficult to diagnose and manage. METHODS: We identified all patients at our institution with bleeding stomal varices from 1989 to 2004. We surveyed all patients undergoing ileal pouch-anal anastomosis from 1997 to 2007 for bleeding anastomotic varices. Finally, we performed a systematic review of the literature focusing on diagnosis and treatment of bleeding stomal varices that included 74 English language studies of 234 patients. RESULTS: We identified 8 patients with bleeding stomal varices. Recognition of stomal varices typically was delayed, particularly when failing to examine the ostomy without the appliance. Stomal variceal bleeding was confirmed by Doppler ultrasound or angiographic imaging. Simple local therapy usually stopped bleeding, albeit temporarily. Sclerotherapy was effective, but at the expense of unacceptable stomal damage. Decompressive therapy was required for secondary prophylaxis, including transjugular intravascular transhepatic shunts (2 patients), surgical portosystemic shunts (2 patients), and liver transplantation (1 patient). No patient with an ileal pouch-anal anastomosis developed anastomotic bleeding from varices. CONCLUSIONS: Primary prevention of bleeding stomal varices requires avoidance of creating enterocutaneous stomas in patients with portal hypertension. Careful inspection of the uncovered ostomy is essential for bleeding stomal varices diagnosis. Once identified, conservative measures will stop bleeding temporarily with definitive therapy required, including transjugular intravascular transhepatic shunts, surgical shunts, or liver transplantation.

Bacteremic sepsis disturbs alveolar perfusion distribution in the lungs of rats.

OBJECTIVE: Sepsis often leads to lung injury, although the mechanisms that initiate this are unclear. One preinjury phenomenon that has not been explored previously is the effect of bacterial (nonlipopolysaccharide) sepsis on the distribution of alveolar perfusion. The goals of our studies were to measure this. DESIGN: Randomized, controlled, prospective animal study. SETTING: University animal laboratory. SUBJECTS: Male Sprague-Dawley rats (450-550 g). INTERVENTIONS: We induced sepsis by placing gelatin capsules containing Escherichia coli and Bacteroides fragilis into the abdomens of rats (n = 9). Empty capsules (n = 6) were placed into the abdomens of controls. After 24 hrs, 4-microm-diameter fluorescent latex particles (2 x 10(8)) were infused into the pulmonary circulation. Sepsis was induced in additional rats and controls to assess lung injury, as follows: Lung histology was performed on eight septic rats and on seven controls; lung lavage was performed on three septic rats and three controls after their plasma albumin had been labeled with Evans blue dye. MEASUREMENTS AND MAIN RESULTS: Confocal microscopy was used to prepare digital maps of latex particle trapping patterns (eight per lung). Analysis of these patterns revealed statistically more clustering (perfusion inhomogeneity) down to tissue volumes less than that of ten alveoli in septic lungs compared with controls (p < or = .05). Bacterial counts and neutrophil counts were significantly higher in the circulation of septic rats (p < or = .05). Blood pressures and arterial PO2s were unchanged. Cell counts in histological images were three-fold higher in septic lungs than in controls (p < or = .05). Lung lavage revealed 0.41 +/- 0.03 mL of plasma in the lungs of septic rats, and 0.06 +/- 0.05 mL in the lungs of controls (p < or = .05). CONCLUSIONS: Bacterial sepsis caused significant maldistribution of interalveolar perfusion in the lungs of rats in the absence of significant lung injury.

Hemorrhage progressively disturbs interalveolar perfusion in the lungs of rats.

Acute hemorrhage is often followed by devastating lung injury. However, why blood loss should lead to lung injury is not known. One possibility is that hemorrhage rapidly disturbs the distribution of microvascular perfusion at the alveolar level, which may be a triggering event for subsequent injury. We showed previously that a 30% blood loss in rats caused significant maldistribution of interalveolar perfusion within 45 min (J Trauma 60:158, 2006). In this report, we describe results of further exploration of this phenomenon. We wanted to know if perfusion distribution was disturbed at 15 min, when vascular pressures were significantly reduced by the blood loss, compared with those at 45 min, when the pressures had returned substantially toward normal. We hemorrhaged rats by removing 30% of their blood volume. We quantified interalveolar perfusion distribution by statistically analyzing the trapping patterns of 4-microm-diameter fluorescent latex particles infused into the pulmonary circulation 15 (red particles) and 45 min (green particles) after blood removal. We used confocal fluorescence microscopy to digitally image the trapping patterns in sections of the air-dried lungs and used pattern analysis to quantify the patterns in tissue image volumes that ranged from 1,300 alveoli to less than 1 alveolus. LogDI, a measure of perfusion maldistribution, increased from 1.00 +/- 0.15 at 15 min after blood loss to 1.62 +/- 0.24 at 45 min (P < 0.001). These values were 0.86 +/- 0.22 (15 min) and 1.12 +/- 0.24 (45 min) in control rats (P = 0.03). Hemorrhage caused the green (45 min)-to-red (15 min) particle distance to decrease from 35.9 +/- 6.5 to 28.0 +/- 5.1 microm (P = 0.024) and the red-to-green particle distance to remain unchanged (30.2 +/- 5.7 microm [red]; 31.5 +/- 10.0 microm [green] [n.s.]). We conclude that hemorrhage caused a progressive increase in interalveolar perfusion maldistribution over 45 min that did not correspond to reduced arterial pressures or altered blood gases. Our particle distance measurements led us to further conclude that this maldistribution occurred in areas that were perfused at 15 min rather than in previously unperfused areas .

Laparoscopic restorative proctocolectomy with ileal S-pouch.

PURPOSE: Restorative proctocolectomy has revolutionized the surgical management of ulcerative colitis and familial polyposis syndromes. Though now evolved to include laparoscopy, this approach has not included alternative pouch designs such as ileal S-pouch reconstruction. This comparative analysis evaluated the combination of laparoscopic-assisted total proctocolectomy with an ileal S-pouch design. METHODS: One hundred fifty-six (65 laparoscopic-assisted) total proctocolectomy and ileal S-pouch-anal anastomosis procedures performed between 2003 to 2007 were identified from a prospective surgical database. Operative time, length of incision, length of hospital stay, complications, and return of bowel function were examined. A cost analysis including preoperative through postoperative hospital stay and operating room and postanesthesia care unit costs was performed. RESULTS: The laparoscopic-assisted total proctocolectomy and ileal S-pouch-anal anastomosis procedures were performed for ulcerative colitis in 60 cases and familial adenomatous polyposis in the remaining 5 patients. Four conversions to open technique occurred (6 percent). Comparing laparoscopic and open procedures, the laparoscopic approach took longer to perform than the open technique (mean 451 minutes vs. 347 minutes open; P < 0.001). The mean hospital stay was 6.3 days in the laparoscopic group vs. 8.2 days in the open group (P < 0.001). A detailed cost analysis revealed similar overall costs between the laparoscopic ($18,700) and open approaches ($18,500). CONCLUSION: Use of a laparoscopic total proctocolectomy with ileal S-pouch-anal anastomosis reconstruction minimizes incision size and shortens hospital stay. At a teaching academic institution, the laparoscopic approach requires longer operative times yet a negligible cost disadvantage.

Acute hypoxia does not alter inter-alveolar perfusion distribution in unanesthetized rats.

Effects of hypoxic vasoconstriction on inter-alveolar perfusion distribution (< or =1000 alveoli) have not been studied. To address this, we measured inter-alveolar perfusion distribution in the lungs of unanesthetized rats breathing 10% O(2). Perfusion distributions were measured by analyzing the trapping patterns of 4 microm diameter fluorescent latex particles infused into the pulmonary circulation. The trapping patterns were statistically quantified in confocal images of the dried lungs. Trapping patterns were measured in lung volumes that ranged between less than 1 and 1300 alveoli, and were expressed as the log of the dispersion index (logDI). A uniform (statistically random) perfusion distribution corresponds to a logDI value of zero. The more this value exceeds zero, the more the distribution is clustered (non-random). At the largest tissue volume (1300 alveoli) logDI reached a maximum value of 0.68+/-0.42 (mean+/-s.d.) in hypoxic rats (n = 6), 0.50+/-0.38 in hypercapnic rats (n.s.) and 0.48+/-0.25 in air-breathing controls (n.s.). Our results suggest that acute hypoxia did not cause significant changes in inter-alveolar perfusion distribution in unanesthetized, spontaneously breathing rats.

Clinically Competent and Fiscally at Risk: Impact of Debt and Financial Parameters on the Surgical Resident.

BACKGROUND: While the costs of medical training continue to increase, surgeon income and personal financial decisions may be challenged to manage this expanding debt burden. We sought to characterize the financial liability, assets, income, and debt of surgical residents, and evaluate the necessity for additional financial training. STUDY DESIGN: All surgical trainees at a single academic center completed a detailed survey. Questions focused on issues related to debt, equity, cash flow, financial education, and fiscal parameters. Responses were used to calculate debt-to-asset and debt-to-income ratios. Predictors of moderate risk debt-to-asset ratio (0.5 to 0.9), high risk debt-to-asset ratio (≥0.9), and high risk debt-to-income ratio (>0.4) were evaluated. All analyses were performed in SPSS v.21. RESULTS: One hundred five trainees completed the survey (80% response rate), with 38% of respondents reporting greater than $200,000 in educational debt. Overall, 82% of respondents had a moderate or high risk debt-to-asset ratio. Residency program, year, sex, and perception of financial knowledge did not correlate with high risk debt-to-asset ratio. Residents with high debt-to-asset ratios were more likely to have a high level of concern about debt (52% vs 0%, p < 0.001) when compared with residents who had low debt-to-asset ratios. The majority (79%) of respondents felt strongly that inclusion of additional financial training in residency education is a critical need. CONCLUSIONS: In a climate of increasingly delayed financial gratification, surgical trainees are on critically unstable financial footing. There is a major gap in current surgical education that requires reassessment for the long-term financial health of residents.

Lipoxin biosynthesis in inflammatory bowel disease.

BACKGROUND AND AIMS: Lipoxins are anti-inflammatory lipid mediators that are produced in gut mucosa, which serve to limit and resolve persistent inflammation. The purpose of this study was to evaluate colonic lipoxin biosynthesis in patients with ulcerative colitis (UC) to establish a possible biochemical basis for persistent inflammation in UC. METHODS: Colonic mucosa from patients with UC or organ donors (controls) was placed into tissue culture for 90 min. The conditioned media was assayed (ELISA) for lipoxin A4 (LXA) and the biologically active isomer 15-epi-LXA4 (aspirin triggered lipoxin, ATL). Mucosal tissue 15-lipoxygenase protein was determined by Western blot. RESULTS: Patient colonic mucosa produced significantly lower (12-fold) amounts of LXA, relative to organ donors. This occurred irregardless of patient steroid treatment. However, patient tissue responded to in vitro aspirin by synthesizing biologically active ATL. For the first time, human colonic mucosa was found to synthesize 15-lipoxygenase-2, an epithelial-derived isoenzyme used for lipoxin synthesis. These levels were significantly lower in UC patients compared to the control tissue. Finally, mice chronically treated with a putative selective 15-lipoxygenase inhibitor (PD 146176) experienced significantly worse intestinal function during experimental colitis, relative to untreated mice. CONCLUSION: Colonic mucosa from UC patients demonstrated defective lipoxin biosynthesis, which may contribute to the inability of these patients to resolve persistent colonic inflammation.

Characterizing readmission in ulcerative colitis patients undergoing restorative proctocolectomy.

BACKGROUND: Postoperative readmissions increase costs and affect patient quality of life. Ulcerative colitis (UC) patients are at a high risk for hospital readmission following restorative proctocolectomy (RP). OBJECTIVE: The objective of this study is to characterize UC patients undergoing RP and identify causes and risk factors for readmission. DESIGN: A retrospective review of a prospectively maintained institutional database was performed. Postoperative readmission rates and reasons for readmission were examined following RP. Univariate and multivariate analyses were performed to evaluate for risk factors associated with readmission. RESULTS: Of 533 patients who met our inclusion criteria, 18.2 % (n = 97) were readmitted within 30 days while 22.7 % (n = 121) were readmitted within 90 days of stage I of RP. Younger patient age (OR 1.825, 95 % CI 1.139-2.957), laparoscopic approach (OR 1.943, 95 % CI 1.217-3.104), and increased length of initial stay (OR 1.155, 95 % CI 1.090-1.225) were all associated with 30-day readmission. The most common reason for readmission was dehydration/ileus/partial bowel obstruction, with 10 % of patients readmitted for this reason within 30 days. CONCLUSIONS: Patients undergoing restorative proctocolectomy are at high risk for readmission, particularly following the first stage of the operation. Novel treatment pathways to prevent ileus and dehydration as an outpatient may decrease the rates of readmission following RP.