Colorectal Cancer: A Systematic Review of the Current Situation and Screening in North and Central Asian Countries.

The prevalence of colorectal cancer (CRC) is increasing in the past few decades. A significant proportion of this increase is from low to middle income countries (LMIC). CRC prevalence is also increasing in North and Central Asian Countries (NCAC). Screening for colorectal cancer has decreased CRC mortality but data regarding screening practices in NCAC is limited.  A literature search was conducted in PubMed/Medline, Embase and Cochrane for current colorectal cancer screening practices in NCAC. Incidence and mortality rates were derived from public health agency websites to calculate age-standardized CRC mortality-to-incidence ratios. Web-based online break-point testing defined as statistical major changes in CRC mortality trends was completed. Among the 677 screened studies, 37 studies met the criteria for inclusion for review. CRC screening in NCAC is not organized, although most countries have cancer registries. The data availability is scarce, and most data is prior to 2017. Most studies are observational. There is minimal data about colonoscopy preparations, adenoma detection and complications rates. The polyp detection rates (PDRs) and adenoma detection rates (ADRs) seem low to optimal in this region. Commonly measured outcomes include participation rate, fecal immunochemical tests (FIT) positivity rate and cost-benefit measures. Lower mortality-to-incidence ratios is seen in countries with screening programs. Kazakhstan and Lithuania with screening programs have achieved breakpoint suggesting major changes in CRC mortality trends. Data about CRC screening varies widely within NCAC. High human developmental index (HDI) countries like Lithuania and Estonia have higher incidence of CRC and mortality. Seven NCAC have CRC screening programs with most utilizing non-invasive methods for screening. Data collection is regional and not organized. The ADR and PDR are low to optimal in this region and cancer detection rates are comparable to other high-income countries (HIC). CRC detection rate is 0.05% for screening in Kazakhstan and 0.2% for screening in Lithuania. Very limited information is available on the actual cost and logistics of implementing a CRC screening program. All NCAC have a cancer registry, with some having a high-quality registry showing national coverage with good validity and completeness. Establishing guideline-based registries and increasing screening efficacy could improve CRC outcomes in NCAC.

A Comparative Analysis of Short-term Patient Outcomes After Laparoscopic Versus Robotic Rectal Surgery.

BACKGROUND: The popularity of robot-assisted colorectal surgery has risen over recent years; however, patient-related advantages over laparoscopic surgery remain uncertain. OBJECTIVE: The goal of this study was to compare short-term patient outcomes following robotic and laparoscopic partial or complete rectal resections. DESIGN: This was a retrospective cohort study. SETTINGS: The study was conducted at 5 large tertiary care Kaiser Permanente medical centers across Southern California. PATIENTS: There were 863 consecutive robotic and laparoscopic pelvic rectal surgeries, including low anterior resections, proctectomies with coloanal anastomosis, and abdominoperineal resections, performed between January 2010 and December 2019. MAIN OUTCOME MEASURES: Short-term patient outcomes, including postoperative length of hospital stay, emergency department returns, and 30-day readmissions, and mortality. RESULTS: A total of 458 surgical procedures were performed via robotic versus 405 via laparoscopic approaches. The robotic group had a higher proportion of male patients (57.4% vs 50.4%; p = 0.04) and a higher proportion of obese (27.1% vs 26.9%; p = 0.02) and overweight patients (36.9% vs 35.1%; p = 0.01). There was no difference in underlying comorbidities of diabetes or smoking, or in the rate of ileostomy creation. After adjusting for Charlson Comorbidity Index, no significant difference was found in emergency department returns between robotic and laparoscopic surgical patients ( p = 0.17). There were no significant outcome differences between the 2 groups with regards to length of stay during procedure, 30-day readmission, or death rates. LIMITATIONS: This study was limited by the lack of randomization in its design, selection of patients for surgical approach, and training and familiarity with robotic rectal surgery. CONCLUSIONS: This study shows length of stay during the procedure and postoperative 30-day readmission rates were generally similar between robotic and laparoscopic patients. Male patients and those with a higher BMI were more likely to have been operated via a robotic method. See Video Abstract at http://links.lww.com/DCR/B857 . UN ANLISIS COMPARATIVO DE LOS RESULTADOS A CORTO PLAZO DE LOS PACIENTES DESPUS DE LA CIRUGA RECTAL LAPAROSCPICA VERSUS LA ROBTICA: ANTECEDENTES:La popularidad de la cirugía colorrectal asistida por robot ha aumentado en los últimos años. Sin embargo, las ventajas relacionadas con el paciente siguen siendo inciertas sobre la cirugía laparoscópica.OBJETIVO:Nuestro objetivo era comparar los resultados de los pacientes a corto plazo después de resecciones rectales completas o parciales robóticas y laparoscópicas.DISEÑO:Este fue un estudio de cohorte retrospectivo.AJUSTE:El estudio se llevó a cabo en cinco grandes centros médicos de Kaiser Permanente de atención terciaria en el sur de California.PACIENTES:Se realizaron 863 cirugías robóticas y laparoscópicas rectales pélvicas consecutivas, incluidas resecciones anteriores bajas, proctectomías con anastomosis coloanal y resecciones abdominoperineales, realizadas entre enero de 2010 y diciembre de 2019.PRINCIPALES MEDIDAS DE RESULTADO:Resultados de los pacientes a corto plazo, incluida la duración de la estancia hospitalaria después del procedimiento, los retornos al departamento de emergencias y los reingresos y la mortalidad a los 30 días.RESULTADOS:Se realizaron un total de 458 procedimientos quirúrgicos a través del robot versus 405 con laparoscopia. El grupo robótico tuvo una mayor proporción de pacientes masculinos (57,4 vs 50,4%, p = 0,04) y una mayor proporción de pacientes obesos (27,1 vs 26,9%, p = 0,02) y con sobrepeso (36,9 vs 35,1%, p = 0,01). No hubo diferencia en las comorbilidades subyacentes de la diabetes y el tabaquismo, y en la tasa de creación de ileostomía. Después de ajustar por el índice de comorbilidad de Charlson, no se encontraron diferencias significativas en los retornos al servicio de urgencias entre los pacientes robóticos y laparoscópicos ( p = 0,17). No hubo diferencias significativas en los resultados entre los dos grupos con respecto a la duración de la estadía durante el procedimiento, las tasas de readmisión a los 30 días y las tasas de muerte.LIMITACIONES:Falta de aleatorización en el diseño del estudio, selección de pacientes para abordaje quirúrgico, capacitación y familiaridad con la cirugía rectal robótica.CONCLUSIONES:Este estudio muestra la duración de la estadía durante el procedimiento y las tasas de reingreso a los 30 días después del procedimiento fueron generalmente similares entre los pacientes robóticos y laparoscópicos. Los pacientes masculinos y aquellos con un índice de masa corporal más alto tenían más probabilidades de haber sido operados mediante un método robótico. Consulte Video Resumen en http://links.lww.com/DCR/B857 . (Traducción-Dr Yolanda Colorado ).

Assessing Knowledge and Perceptions of Colorectal Cancer Screening in Armenia.

BACKGROUND: Armenia has a high incidence of and mortality from colorectal cancer (CRC). No organized screening programs for CRC exist in Armenia. This study seeks to evaluate knowledge of and attitudes toward CRC and screening programs in Armenia. METHODS: Adults aged 40-64 y were administered a survey using convenience sampling throughout polyclinics in Yerevan city. Survey questions were based on the Health Belief Model and were translated and modified for local relevance. RESULTS: A total of 368 surveys were completed. Eighty-four percent had knowledge of CRC, 91% believed that early detection leads to improved outcomes, but only 22% had knowledge of screening. Women were more likely to have knowledge of CRC (odds ratio 2.19, P < 0.05). Although 19% have personally worried about having CRC, only 7% admitted to discussing their worries with a provider and 76% were willing to undergo screening if recommended by their doctor. Seventy-eight percent of respondents would only undergo screening if free or less than ~$20 USD. CONCLUSIONS: Self-reported knowledge of CRC is high, whereas knowledge of screening remains low in Armenia. There is a willingness to undergo screening if recommended by a health care professional; however, this willingness is cost-sensitive. Interventions aimed at (1) increasing awareness of the disease and screening tests, (2) improving physician counseling, and (3) reducing financial barriers to screening should be considered along with the implementation of a national screening program in Armenia.

Postoperative Physician Phone Calls as a Method to Decrease Urgent Care and Emergency Department Returns After Ambulatory General Surgery.

Unplanned returns after ambulatory surgery pose a burden to patients and health care providers alike. We hypothesized that a postoperative phone call by a physician would decrease avoidable returns to urgent care (UC) or the emergency department (ED) in the week after anorectal (AR), laparoscopic cholecystectomy (LC), inguinal hernia repair (IHR), and umbilical hernia repair (UHR) operations. A retrospective analysis from 1/2011 to 12/2015 across 14 Kaiser hospitals was conducted to determine baseline UC/ED return rates of patients pre-call. Between 10/2017 and 06/2019, physicians placed phone calls to patients within postoperative days (PODs) 1-4. The cohorts were compared using chi-squared analysis with significance determined at P < .05. In total, 276 patients received a call, with the majority placed on PODs 1-3. There were no statistically significant differences in return rates between the pre- and post-call groups. All of the AR, 50.0% of LC, 66.7% of IHR, and 50.0% of UHR patients returned prior to phone call placement. Our data indicate that a physician phone call does not help in decreasing UC/ED returns. However, it is noteworthy that many of the returns occurred pre-call placement. Future directions should be aimed at placing earlier postoperative phone calls.

Ostomy Complications in Crohn's Disease.

Ostomy creation is a routine surgical procedure that has earned its place high in the surgeon's armamentarium in dealing with challenging situations. However, it is not without its complications. In this article, we review the common complications including parastomal hernia, prolapse, mucocutaneous junction separation with ischemia and stenosis, peristomal skin conditions, and infections. Additionally, we review conditions that arise in association with underlying Crohn's disease, such as peristomal inflammation, fistula formation, and pyoderma gangrenosum.

Unplanned Returns to Care within Seven Days after Anorectal Surgery: Can they be Avoided?

With rates up to 50 per cent, unanticipated returns after anorectal surgery remain a major issue. A retrospective analysis was performed on 5929 anorectal operations from January 2011 to December 2015 across 14 Kaiser Permanente Southern California medical centers. Data were gathered on the cause, frequency and timing of unplanned returns to the ED and urgent care. Of all patients, 246 (4%) returned with a nonavoidable diagnosis and 243 (4%) returned with one of four avoidable diagnoses: pain, constipation, urinary retention, and nausea/vomiting. Seventy four per cent of avoidable diagnoses returns occurred within the first four postoperative days, with 48 per cent between days 2 and 4. In patients older than 50 years of age, males showed higher urinary retention (P = 0.001), whereas females had higher constipation (P < 0.001). Contrarily, pain was higher for both males (P = 0.02) and females (P < 0.001) less than 50 years old. In a separate subanalysis on anesthesia type, both constipation (P = 0.03) and urinary retention (P = 0.01) showed double the return rate in the general versus local/monitored anesthesia care group, whereas pain (P = 0.15) and nausea/vomiting (P = 0.20) showed no differences. Half of returns fall into a category that is potentially avoidable with preemptive interventions.

An Enhanced Recovery After Surgery (ERAS) Protocol for Ambulatory Anorectal Surgery Reduced Postoperative Pain and Unplanned Returns to Care After Discharge.

BACKGROUND: Ambulatory surgery for anorectal procedures has been proven to be safe and effective. Specific perioperative pathways combining multiple interventions have been shown to optimize recovery and outcomes associated with inpatient colorectal surgery. However, there are no major studies describing and evaluating a standardized protocol for ambulatory anorectal surgery. The purpose of this study was to evaluate the outcomes of a modified enhanced recovery after surgery (ERAS) protocol for ambulatory anorectal surgery. METHODS: This was a retrospective review of prospectively collected data from 14 Southern California Kaiser Permanente medical centers. An eight-item protocol including: preoperative education, preoperative distribution of prescriptions, preoperative carbohydrate treatment, multimodal analgesia, preferential use of monitored anesthesia care (MAC), routine use of local anesthesia/regional blocks, intraoperative restriction of intravenous fluids, and post-discharge phone call. Postoperative pain scores and preventable returns to the emergency department or urgent care were assessed. RESULTS: Postoperative pain scores were reduced when all eight elements of the protocol were delivered (p = 0.005). On multivariate analysis, there was reduced postoperative pain when preoperative carbohydrate treatment was completed (p = 0.002), with MAC (p = 0.003), and when multimodal analgesia was used (p = 0.02). There were decreased preventable returns to the emergency department or urgent care when MAC was used (p = 0.03); there were more returns for constipation (p = 0.04) but fewer returns for pain (p = 0.002) after preoperative carbohydrate treatment. Local anesthesia was associated with fewer returns for constipation (p = 0.01). CONCLUSIONS: Implementation of a standardized ERAS protocol for ambulatory anorectal surgery decreased postoperative pain and unplanned return visits to emergency care.

Same-Day Discharge in Laparoscopic Acute Non-Perforated Appendectomy.

BACKGROUND: Small studies done during the past decade have demonstrated same-day discharge after appendectomy as an option for non-perforated appendicitis. Here we have examined a large cohort to confirm that same-day discharge in acute non-perforated appendicitis is a safe option. STUDY DESIGN: This was a retrospective study of patients from 14 Southern California Region Kaiser Permanente medical centers. All patients older than 18 years of age with acute, non-perforated appendicitis who underwent a laparoscopic appendectomy between 2010 and 2014 were included. We compared patients discharged on the day of surgery with patients hospitalized for 1 night. We examined readmission rates, complication rates, postoperative emergency department visits, postoperative diagnostic or therapeutic radiology visits, reoperations, and cost of treatment. RESULTS: The cohort was composed of 12,703 patients; 6,710 patients were in the same-day discharge group and 5,993 patients were in the hospitalized group. Patients in the same-day discharge group had a lower rate of readmission within 30 days when compared with the hospitalized group (2.2% vs 3.1%; p < 0.005). In both groups, postoperative rates of visits to emergency or radiology department for diagnostic or therapeutic imaging studies were statistically similar. Postoperative general surgery department visits were slightly higher in the hospitalized group (85% vs 81%; p < 0.001). CONCLUSIONS: Adult patients with acute, non-perforated appendicitis can be discharged safely on the day of surgery without higher rates of postoperative complication or readmission rates compared with those hospitalized after surgery. In addition, same-day discharge in this patient group is cost-effective.

Long-term results of ligation of intersphincteric fistula tract (LIFT) for fistula-in-ano.

BACKGROUND: Ligation of intersphincteric fistula tract is a novel surgical technique in the treatment of transsphincteric fistula-in-ano that has been shown to be successful in the short term. Median follow-up in current literature ranges from 5 to 9 months. However, the long-term success rate is unknown. OBJECTIVE: This study describes our long-term results in performing the ligation of intersphincteric fistula tract procedure. DESIGN: This study is a retrospective review. PATIENTS: Thirty-eight patients from August 2008 to October 2011 were evaluated. INTERVENTIONS: All patients underwent the ligation of intersphincteric fistula tract for fistula-in-ano. MAIN OUTCOME MEASURES: Patient and fistula characteristics, primary healing rate, secondary healing rate, previous treatments, and failures were reviewed. RESULTS: The median follow-up was 26 months (range, 3-44 months), and 26 patients (68%) were followed for greater than 12 months. The overall primary healing rate was 61% (23 of 38), and it was 62% (16 of 26) in patients followed for over 12 months. Eighty percent (12/15) of the failures are early failures (persistent symptoms or failure at ≤6 months), and 20% are late failures (>6 months) with 1 failure occurring 12 months postprocedure. Increase in length of fistula tract was associated with decreased healing (OR 0.55, 95% CI 0.34-0.88, p = 0.01). There were no intraoperative complications and no reported incontinence. CONCLUSION: Our study demonstrates favorable long-term results for the ligation of intersphincteric fistula tract procedure. It appears that long tracts negatively affect healing, and late failures can occur up to 12 months postoperatively. Understanding the type of failure can help guide subsequent treatment to maximize healing success.

Preoperative serum albumin but not prealbumin is an excellent predictor of postoperative complications and mortality in patients with gastrointestinal cancer.

Preoperative serum albumin level is well recognized as a general predictor of adverse surgical outcomes in patients with gastrointestinal (GI) malignancy. Whether serum albumin or prealbumin levels can better predict postoperative surgical complications and death remains unknown. A retrospective review of 641 consecutive patients operated nonemergently for GI malignancies between January 1, 1997, and July 31, 2008, disclosed that 104 patients (16.2%) had complications and 23 (3.6%) subsequently died. All 641 patients had preoperative determination of serum albumin level (cost $0.13 per test), whereas 379 (59.1%) also had preoperative determination of serum prealbumin level (cost $2.27 per test). An albumin level below the discriminatory threshold of 3.2 g/dL was a significant predictor of overall postoperative morbidity, infectious and noninfectious complications, and mortality (all P < 0.001). In contrast, a prealbumin level below the discriminatory threshold of 18 mg/dL was a predictor of only overall morbidity (P = 0.014) and infectious complications (P = 0.024), but not of noninfectious complications or mortality (P = nonsignificant). We conclude that compared with the preoperative serum prealbumin level, the albumin level has superior predictive value for overall postoperative morbidity, both infectious and noninfectious complications, and mortality. The inclusion of serum prealbumin level in the routine preoperative testing of patients with GI malignancy for the purpose of predicting postoperative outcomes is neither clinically necessary nor cost-effective.

Early result of ligation of the intersphincteric fistula tract for fistula-in-ano.

PURPOSE: The ligation of the intersphincteric fistula tract is a new surgical procedure without any use of biologic material. The purpose of this study is to present our early results with this novel technique. METHODS: A retrospective review of patients who underwent the procedure for high transsphincteric fistulas was analyzed. The procedure was performed by a single surgeon. Patient and fistula characteristics, complications, and recurrences were reviewed. RESULTS: Twenty-five patients underwent the ligation of intersphincteric fistula tract procedure. All the patients had transsphincteric fistulas that were not suitable for fistulotomy. All patients underwent the procedure on an outpatient basis with a median follow-up of 24 weeks (range, 8-52 wk). Of the 25 patients, 17 (68%) healed completely and did not require any further surgical treatment. Eight of the 25 patients had persistent symptoms: 5 patients had a clear tract with an internal opening, 2 patients had a draining sinus without an identifiable internal opening, and 1 patient presented with an intersphincteric fistula, which was at the site of the intersphincteric groove incision. There were no statistically significant differences in recurrence rates with regard to the presence of a seton at the time of surgery, history of previous operations such as mucosal advancement flap, or seton placement. CONCLUSION: The ligation of intersphincteric fistula is a promising sphincter-preserving procedure that is simple and safe, and it does not require expensive biologic material. Our early data confirm a low recurrence rate with a primary healing rate of 68%.

The use of human acellular dermal matrix for chest wall reconstruction.

BACKGROUND: Reconstruction of chest wall defects has evolved, but challenges remain. This is particularly true when defects are large or contamination is present. Although numerous materials are available for reconstruction, acellular dermal matrix has the advantage of becoming vascularized and incorporated autologously. By its resistance to infection and lack of adhesion formation, it is a promising although expensive alternative to synthetic materials in some circumstances. This report examines our experience with human acellular dermal matrix (HADM) in reconstruction of major chest wall and diaphragmatic defects. METHODS: A retrospective study was conducted of all patients who underwent thoracic reconstruction using HADM between March 2007 and March 2010 at Harbor-University of California-Los Angeles Medical Center. Data acquisition included demographics, surgical indications, operative details, complications, and follow-up evaluation. RESULTS: Ten patients were identified. Indications included thoracic tumor resection in 5, Clagett procedure modification for postpneumonectomy empyema in 2, resection of chest wall osteomyelitis in 2, and pneumonectomy for multiple aspergillomata in 1. Complications occurred in 4 patients and included respiratory failure, pneumonia, and wound seromas. All wounds healed without need to remove or revise the HADM, and sound chest wall closure was achieved in every case. CONCLUSIONS: HADM is an effective but expensive alternative to synthetic mesh in reconstruction of chest wall and diaphragmatic defects. It is particularly attractive for use under conditions of potential or overt contamination.

Use of clinical triage criteria decreases monitored care bed utilization in gallstone pancreatitis.

Admission indicators for monitored care in gallstone pancreatitis have been lacking. Recently, we established three criteria for admission to intensive care unit or step down versus ward beds: (1) concomitant cholangitis, (2) heart rate >110 beats/min, and (3) blood urea nitrogen >15 mg/dL. The purpose of this study was to determine whether these criteria would be effective in decreasing monitored care bed utilization without adversely affecting outcomes. A retrospective review of all patients with gallstone pancreatitis at a public teaching hospital was performed (2003-2009). A comparison was made of patients before (2003-2005, Period 1) and after (2006-2009, Period 2) establishment of monitored care triage criteria. Over the study period, there were 379 patients. The median Ranson score for both periods was 1. The median ages were 41 and 39, (P = 0.7). In Period 1, 28 per cent of patients were admitted to the intensive care unit/step down unit versus 12 per cent in Period 2. None of the patients required transfer from the ward to a monitored care setting in Period 2. There were no mortalities in either period. In conclusion, the presence of concomitant cholangitis, heart rate >110, and blood urea nitrogen >15 are useful and safe triage criteria for admission to a monitored care setting. Use of these criteria significantly decreased monitored care bed utilization and resulted in fewer mis-triages without adversely affecting patient outcomes.

Characteristics of colorectal cancer among Asian Americans.

Colorectal cancer (CRC) is third in mortality rate amongst Asian Americans. However, CRC characteristics in this patient population have been poorly defined. A retrospective review at an urban tertiary hospital located in an underserved region was performed to determine CRC characteristics for Asian Americans in comparison to other races. Four hundred fourteen patients were represented by Hispanics (n=161), African Americans (n=101), Asians (n=83), and Whites (n=69). The majority of Asian American patients (n=70, 84%) presented with a left-sided lesion. This proportion was higher than that seen in African Americans (59%, P < 0.0003), Hispanics (66%, P < 0.0033), and Whites (63%, P < 0.0036). Thirty-six Asian American patients presented with Stage III disease which was the most frequent presenting stage for this patient population and also statistically higher than all the other races. Furthermore, Asian Americans in this study still presented predominantly with left-sided lesions and in a more advanced stage. These findings suggest a potential benefit of initially offering flexible sigmoidoscopy given the decreased compliance among Asian Americans to obtain routine CRC screening. Ultimately, this modality may be more acceptable, leading to higher compliance for CRC screening in Asian Americans without likely degradation in cancer detection rates.

Successful enhanced recovery program after colorectal surgery in a county institution.

Enhanced recovery programs after colorectal surgery have gained acceptance recently as they have shown a decrease length of hospital stay. However, these pathways require strict adherence to standardized programs with patient education and high compliance. This study was designed to assess the feasibility of such a program in a large county hospital. A retrospective review was performed of 54 consecutive patients who underwent laparoscopic or open segmental colorectal resection without an ostomy. The first 27 patients were treated in a conventional manner, whereas the latter 27 were treated using a protocol promoting early feeding and ambulation with decreased intravenous fluids and narcotic use. There were no baseline differences between the groups, however, there was a significant difference in the patients treated with the enhanced recovery program in terms of less intravenous fluids administered in surgery (P = 0.001), and over the subsequent 3 days (P = 0.0017), with a decrease in length of hospital stay of 4 compared with 6 days (P = 0.003). There were no differences in terms of complication and readmission rates. Based on this study, we conclude that strict adherence to a standard enhanced recovery program was effective in reducing hospital stay in patients undergoing colorectal resection without any increase in complications.

The public mock oral: a useful tool for examinees and the audience in preparation for the American Board of Surgery Certifying Examination.

OBJECTIVE: The objective of the study was to investigate the value of an educational program instituted in our general surgery residency training in preparation for the American Board of Surgery (ABS) Certifying Examination (CE). DESIGN: From 2006 to 2009, a series of public mock oral examinations were administered by the program director to PGY residents 4 through 6 on a variety of surgery topics in front of all residents, faculty, and medical students. Anonymous surveys (5-point Likert scale) were collected from both the examinees and the audience to determine the perceived utility of the mock oral. Performance on the ABS CE for residents who partook in the program was compared with the five previous years. SETTING: The study was undertaken at Harbor-University of California at Los Angeles (UCLA) Medical Center, a level I trauma center in Los Angeles County. RESULTS: Overall 201 surveys were collected, 170 from the audience and 31 from examinees. The surveys demonstrated a high and equal level of satisfaction for both examinees (4.8) and the audience (4.6, p = 0.12). First-time pass rates on the ABS CE increased from 88% (38/43) before the public mock oral to 100% (19/19) after the mock oral (p = 0.3). CONCLUSIONS: The mock oral examination, which is conducted in a conference format in front of an audience of faculty and trainees, is a valuable educational tool as it helps both the examinee and the audience in preparation for the ABS CE. In addition, it has an educational value for those who are not preparing for the CE as it is perceived to expand surgical knowledge.

Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study.

OBJECTIVE: We hypothesized that laparoscopic cholecystectomy performed within 48 hours of admission for mild gallstone pancreatitis, regardless of resolution of abdominal pain or abnormal laboratory values, would result in a shorter hospital stay. SUMMARY OF BACKGROUND DATA: Although there is consensus among surgeons that patients with gallstone pancreatitis should undergo cholecystectomy to prevent recurrence, the precise timing of laparoscopic cholecystectomy for mild disease remains controversial. METHODS: Consecutive patients with mild pancreatitis (Ranson score