Defining diverticular fistula through inpatient admissions: a population study.

BACKGROUND: Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level. METHODS: A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed. RESULTS: A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2 years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20 days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81 days, p < .0001) than those who received medical treatment alone. CONCLUSION: Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

A New Bibliometric Index: The Top 100 Most Disruptive and Developmental Publications in Colorectal Surgery Journals.

BACKGROUND: A new bibliometric index called the disruption score was recently proposed to identify innovative and paradigm-changing publications. OBJECTIVE: The goal was to apply the disruption score to the colorectal surgery literature to provide the community with a repository of important research articles. DESIGN: This study is a bibliometric analysis. SETTINGS: The 100 most disruptive and developmental publications in Diseases of the Colon & Rectum, Colorectal Disease, International Journal of Colorectal Disease, and Techniques in Coloproctology were identified from a validated data set of disruption scores and linked with the iCite National Institutes of Health tool to obtain citation counts. MAIN OUTCOME MEASURES: The primary outcomes measured were the disruption score and citation count. RESULTS: We identified 12,127 articles published in Diseases of the Colon & Rectum (n = 8109), International Journal of Colorectal Disease (n = 1912), Colorectal Disease (n = 1751), and Techniques in Coloproctology (n = 355) between 1954 and 2014. Diseases of the Colon & Rectum had the most articles in the top 100 most disruptive and developmental lists. The disruptive articles were in the top 1% of the disruption score distribution in PubMed and were cited between 1 and 671 times. Being highly cited was weakly correlated with high disruption scores (r = 0.09). Developmental articles had disruption scores that were more strongly correlated with citation count (r = 0.18). LIMITATIONS: This study is subject to the limitations of bibliometric indices, which change over time. DISCUSSION: The disruption score identified insightful and paradigm-changing studies in colorectal surgery. These studies include a wide range of topics and consistently identified editorials and case reports/case series as important research. This bibliometric analysis provides colorectal surgeons with a unique archive of research that can often be overlooked but that may have scholarly significance. See Video Abstract at http://links.lww.com/DCR/B639.UN NUEVO INDICE BIBLIOMÉTRICO: LAS 100 MAS IMPORTANTES PUBLICACIONES EN INNOVACIONES DESESTABILIZADORAS Y DE DESARROLLO EN LAS REVISTAS DE CIRUGÍA COLORRECTALANTECEDENTES:Un nuevo índice bibliométrico llamado innovación desestabilizadora y de desarrollo ha sido propuesto para identificar publicaciones de vanguardia y que pueden romper paradigmas.OBJETIVO:La meta fué aplicar el índice de desestabilización a la literature en cirugía colorectal para aportar a la comunidad con un acervo importante de artículos de investigación.DISEÑO:Un análisis bibliométrico.PARAMETROS:Las 100 publicaciones mas desestabilizadores y de desarrollo en las revistas: Diseases of the Colon and Rectum, Colorectal Disease, International Journal of Colorectal Disease, y Techniques in Coloproctology se recuperaron de una base de datos validada con puntuaciones de desestabilización y se ligaron con la herramienta iCite NIH para obtener la cuantificación de citas.PRINCIPAL MEDIDA DE RESULTADO:El índice desestabilizador y la cuantificación de citas.RESULTADOS:Se identificaron 12,127 articulos publicados en Diseases of the Colon and Rectum (n = 8,109), International Journal of Colorectal Disease (n = 1,912), Colorectal Disease (n = 1,751), y Techniques in Coloproctology (n = 355) de 1954-2014. Diseases of the Colon and Rectum representó la mayoría de las publicaciones dentro de la lista de los 100 mas desestabilizadores y de desarrollo. Esta literatura desestabilizadora se encuentra en el principal 1% de la distribución de la puntuacón desestabilizadora en PubMed y se citaron de 1 a 671 veces. El ser citado con frecuencia se relacionó vagamente con las puntuaciones de desastibilización (r = 0.09). Los artículos de desarrollo tuvieron puntuaciones de desestabilización que estuvieron muy correlacionados con la cuantificación de las citas (r = 0.18).LIMITACIONES:Las sujetas a las limitaciones de los índices bibliométricos, que se modifican en el tiempo.DISCUSION:La putuación de desestabilicación identificó trabajos perspicaces, pragmáticos y modificadores de paradigmas en cirugía colorrectal. Es de interés identificar que se incluyeron una gran variedad de temas y en forma consistente editoriales, reportes de casos y series de casos que representaron una investigación importante. Este análisis bibliométrico aporta a los cirujanos colorrectales de un acervo de investigación único que puede con frecuencia pasarse por alto, y sin embargo tener una gran importancia académica. Consulte Video Resumen en http://links.lww.com/DCR/B639. (Traducción- Dr. Miguel Esquivel-Herrera).

Keep Them on the Table: Outcomes Are Improved After Minimally Invasive Colectomy Despite Longer Operative Times in Patients With High-Risk Colon Cancer.

BACKGROUND: For high-risk patients, traditional surgical dogma advises open operations, with short operative times, to "get them off the table" instead of longer minimally invasive surgery approaches. OBJECTIVE: The aim of this study was to compare postoperative outcomes in patients with high-risk colon cancer undergoing elective longer minimally invasive surgery operations compared with shorter open operations. DESIGN: Retrospective comparative cohort study. SETTINGS: Interventions were performed in hospitals participating in the national surgical database. PATIENTS: The National Surgical Quality Improvement Program database was used to identify patients with colon cancer with ASA class 3 to 4 undergoing right and sigmoid colectomy between 2012 and 2017. MAIN OUTCOME MEASURES: Thirty-day postoperative outcomes were compared between short open and long minimally invasive groups. RESULTS: A total of 3775 patients were identified as having undergone long minimally invasive right colectomy and short open right colectomy (33% open, 67% minimally invasive surgery), and 1042 patients were identified as having undergone long minimally invasive sigmoid colectomy and short open sigmoid colectomy (36% open, 64% minimally invasive). Patients undergoing long minimally invasive right colectomy had significantly lower rates of overall morbidity, severe adverse events, mortality, superficial surgical site infections, and wound disruptions, as well as discharge to a higher level of care and shorter length of stay ( p < 0.05). Patients undergoing long minimally invasive sigmoid colectomy had decreased rates of overall morbidity, severe adverse events, and length of stay, as well as discharge to a higher level of care compared with the patients undergoing short open sigmoid colectomy ( p < 0.05). LIMITATIONS: This study was limited by the retrospective nature and standardized outcome measures. CONCLUSIONS: In high-risk patients undergoing colectomy for colon cancer, outcomes were worse with shorter open compared with longer minimally invasive surgery operations. Focus should shift from getting patients "off the table" faster to longer, but safer, minimally invasive surgery in high-risk patients. See Video Abstract at http://links.lww.com/DCR/B642 . MANTNGALOS SOBRE LA MESA HAY MEJORES RESULTADOS DESPUS DE COLECTOMA MNIMAMENTE INVASIVA A PESAR DE TIEMPOS QUIRRGICOS MS PROLONGADOS EN PACIENTES CON CNCER DE COLON DE ALTO RIESGO: ANTECEDENTES:Para los pacientes de alto riesgo, el dogma quirúrgico tradicional aconseja operaciones abiertas, con tiempos quirúrgicos cortos, con el fin de "sacarlos de la mesa" en lugar de enfoques quirúrgicos mínimamente invasivos más prolongados.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios en pacientes electivos de cáncer de colon de alto riesgo sometidos a operaciones de cirugía mínimamente invasiva más prolongadas en comparación con operaciones abiertas más cortas.DISEÑO:Los resultados posoperatorios de pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha o sigmoidea se compararon en un análisis multivariado. Se comparó el grupo de colectomía derecha abierta corta (tiempo operatorio <116 minutos) y colectomía derecha mínimamente invasiva larga (tiempo operatorio> 132 minutos). También se compararon la colectomía sigmoidea abierta corta (tiempo operatorio <127 minutos) y la colectomía sigmoidea mínimamente invasiva larga (tiempo operatorio> 161 minutos).ESCENARIO:Las intervenciones se realizaron en hospitales participantes en la base de datos quirúrgica nacional.PACIENTES:La base de datos del Programa Nacional de Mejoramiento de la Calidad Quirúrgica se utilizó para identificar a los pacientes con cáncer de colon con clase 3-4 de la Sociedad Americana de Anestesiología sometidos a colectomía derecha y sigmoidea entre 2012-2017.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon los resultados posoperatorios a los treinta días entre el grupo de procedimientos abiertos cortos y el de mínimamente invasivos largos.RESULTADOS:Se identificó un total de 3.775 pacientes sometidos a colectomía derecha mínimamente invasiva larga y colectomía derecha abierta corta (33% abierta, 67% cirugía mínimamente invasiva) y se identificaron 1042 pacientes sometidos a colectomía sigmoidea mínimamente invasiva larga y colectomía sigmoidea abierta corta (36% abierta, 64% mínimamente invasiva). Los pacientes con colectomía derecha larga mínimamente invasiva tuvieron significativamente menor morbilidad general, eventos adversos graves, mortalidad, infecciones superficiales del sitio quirúrgico, dehiscencia de herida, alta a un nivel más alto de atención y estadía más corta ( p <0.05). Los pacientes con colectomía sigmoidea mínimamente invasiva prolongada tuvieron menor morbilidad general, eventos adversos graves, duración de la estadía y alta a un nivel más alto de atención en comparación con los pacientes con colectomía sigmoidea abierta corta ( p <0.05).LIMITACIONES:Este estudio estuvo limitado por la naturaleza retrospectiva y las medidas de resultado estandarizadas.CONCLUSIONES:En los pacientes de alto riesgo sometidos a colectomía por cáncer de colon, los resultados fueron peores con operaciones abiertas más cortas en comparación con operaciones mínimamente invasivas más largas. El enfoque debe pasar de hacer que los pacientes "salgan rápido de la mesa quirúrgica" a una cirugía mínimamente invasiva más prolongada pero más segura, en pacientes de alto riesgo. Consulte Video Resumen en http://links.lww.com/DCR/B642 . (Traducción-Dr. Jorge Silva Velazco ).

Surgical Residents' Perspective on Informed Consent-How Does It Compare With Attending Surgeons?

BACKGROUND: The informed consent discussion (ICD) is a compulsory element of clinical practice. Surgical residents are often tasked with obtaining informed consent, but formal instruction is not included in standard curricula. This study aims to examine attitudes of surgeons and residents concerning ICD. MATERIALS AND METHODS: A survey regarding ICD was administered to residents and attending surgeons at an academic medical center with an Accreditation Council for Graduate Medical Education-accredited general surgery residency. RESULTS: In total, 44 of 64 (68.75%) residents and 37 of 50 (72%) attending surgeons participated. Most residents felt comfortable consenting for elective (93%) and emergent (82%) cases, but attending surgeons were less comfortable with resident-led ICD (51% elective, 73% emergent). Resident comfort increased with postgraduate year (PGY) (PGY1 = 39%, PGY5 = 85%). A majority of participants (80% attending surgeons, 73% residents) believed resident ICD skills should be formally evaluated, and most residents in PGY1 (61%) requested formal instruction. High percentages of residents (86%) and attendings (100%) believed that ICD skills were best learned from direct observation of attending surgeons. CONCLUSIONS: Resident comfort with ICD increases as residents advance through training. Residents acknowledge the importance of their participation in this process, and in particular, junior residents believe formal instruction is important. Attending surgeons are not universally comfortable with resident-led ICDs, particularly for elective surgeries. Efforts for improving ICD education including direct observation between attending surgeons and residents and formal evaluation may benefit the residency curriculum.

It Takes a Village: The First 100 Patients Seen in a Multidisciplinary Pelvic Floor Clinic.

OBJECTIVE: This study aimed to assess the characteristics of patients assessed and treated at a multidisciplinary pelvic floor program that includes representatives from multiple specialties. Our goal is to describe the process from triaging patients to the actual collaborative delivery of care. This study examines the factors contributing to the success of our multidisciplinary clinic as evidenced by its ongoing viability. METHODS: This is a descriptive study retrospectively analyzing a prospectively maintained database that included the first 100 patients seen in the Program for Abdominal and Pelvic Health clinic between December 2017 and October 2018. We examined patient demographics, their concerns, and care plan including diagnostic tests, findings, treatments, referrals, and return visits. RESULTS: The clinic met twice monthly, and the first 100 patients were seen over the course of 10 months. The most common primary symptoms were pelvic pain (45), constipation (30), bladder incontinence (27), bowel incontinence (23), high tone pelvic floor dysfunction (23), and abdominal pain (23); most patients had more than one presenting symptom (76). The most common specialties seen at the first visit to the clinic included gastroenterology (56%), followed by physical medicine and rehabilitation (45%), physical therapy (31%), female pelvic medicine and reconstructive surgery (25%), behavioral health (19%), urology (18%), and colorectal surgery (13%). Eleven patients were entirely new to our hospital system. Most patients had diagnostic tests ordered and performed. CONCLUSIONS: A multidisciplinary clinic for abdominal and pelvic health proves a sustainable model for comprehensive treatment for patients with pelvic floor dysfunction, including difficulties with defecation, urination, sexual dysfunction, and pain.

I want to go home: should we abandon open surgery for treatment of rectal prolapse? Consideration of discharge destination following surgery for rectal prolapse.

AIM: Despite the financial and value-based implications associated with higher levels of care at discharge, few studies have evaluated modifiable treatment factors that may optimize postacute care. The aim of this work was to assess the association between operative approach and disposition to a higher level of care and other outcomes following surgery for rectal prolapse. METHOD: Using a retrospective cohort study design, the database of the National Surgical Quality Improvement Program was used to identify patients with rectal prolapse who underwent perineal repair or open or laparoscopic rectopexy with or without resection between 2012 and 2017. Discharge destination and 30-day postoperative outcomes were compared using propensity score mathcing and weighting. Nomograms generated using multivariable regression calculated the risk of requiring higher levels of care upon discharge and morbidity. RESULTS: Propensity-score analysis included 3000 patients [1500 in the perineal group, 580 in the open abdominal group and 920 in the minimally invasive (MIS) group]. Patients who received open abdominal surgery were more likely to require elevation of care at destination compared with those who received perineal surgery (OR 1.65, 95% CI 1.22-1.24) and MIS abdominal surgery (OR 1.80, 95% CI 1.18-2.76). Similar effects were seen for overall morbidity. Increased age, higher American Society of Anesthesiologists class, congestive heart failure, dependent functional status and open surgery were independent predictors of discharge to higher level of care (c-statistic = 0.79). CONCLUSION: Open surgery compared with MIS and perineal surgery was associated with higher levels of discharge disposition following rectal prolapse surgery. Future research should continue to identify modifiable treatment factors that reduce poor postoperative outcomes among patients with rectal prolapse.

Value of an interactive phone application in an established enhanced recovery program.

PURPOSE: An interactive mobile phone application was added to an established Enhanced Recovery After Surgery (ERAS) program to determine the impact on ERAS compliance as well as clinical outcomes. METHODS: We identified patients undergoing elective colorectal surgery enrolled in our ERAS program from February 2017 to July 2018. Patients enrolled in a phone application were compared with those not enrolled in terms of age, sex, diagnosis, operative approach, bowel preparation, oral intake and solid food intake, ERAS pathway adherence, and clinical outcomes. RESULTS: A total of 289 patients were included: 147 enrolled and 142 not enrolled in the phone application. The mean age of enrollees was 53.0 years, compared with 58.3 years for the non-enrollees (p = 0.003). The mean ERAS pathway medication adherence for enrollees was 82.1% versus 76.8% for those not enrolled (p = 0.005). The mean LOS and SSI rates for those enrolled versus not enrolled in the phone application was 4.4 days versus 6.4 days (p = 0.006) and 3.4% versus 11.3% (p = 0.019), respectively. There was no significant difference in readmission rates between enrollees and non-enrollees (15% versus 10.6%, p = 0.345). The mean total cost of patients enrolled was $11,560; total cost of those not enrolled was $13,946 (p = 0.024). CONCLUSIONS: Use of an interactive phone application is associated with improved medication ERAS adherence along with significant reduction in length of stay and SSI rates without increasing total cost.

Early feeding in colorectal surgery patients: safe and cost effective.

PURPOSE: Enhanced recovery after surgery (ERAS) pathways has demonstrated improved outcomes in colorectal surgery. An important component of ERAS is early oral intake. The aim of this study is to determine the impact of early oral intake in patients following colorectal surgery. METHODS: A retrospective analysis of patients who underwent colectomy and proctectomy at an academic institution from January 2015 to November 2018 was performed. Postoperative outcomes were compared between patients who had postoperative day 0 (POD 0) oral intake and those who did not. RESULTS: A total of 436 ERAS patients had oral intake timing documented. The majority of patients were women (241, 55.3%) and white (313, 71.8%). The mean age was 57 ± 15.09. Patients who had early intake were found to have lower 30-day overall morbidity and length of stay (p < 0.05), and no difference in serious adverse events. Additionally, hospital costs were lower in the POD 0 feeding group for all patients (p < 0.05). CONCLUSION: We have demonstrated that early oral feeding in an established ERAS pathway is associated with improved clinical outcomes as well as decreased total hospital costs. Early postoperative feeding is safe in colorectal patients and should be prioritized to decrease complications and healthcare costs.

A national analysis of operative treatment of adult patients with Hirschsprung's disease.

PURPOSE: Hirschsprung's disease is primarily a disease of infancy, but in rare cases, adults with this condition require surgery. The aim of this study is to identify the types of operations and postoperative outcomes in adults with Hirschsprung's disease on a national level. METHODS: The National Surgical Quality Improvement Program database was used to perform a retrospective review of all adult patients diagnosed with Hirschsprung's disease. Patients were divided into two groups depending on the type of operation: restoration of bowel continuity or diversion of fecal stream; clinicopathologic data and 30-day outcomes were compared between the two groups. RESULTS: A total of 32 patients were analyzed. Fourteen patients (43.8%) underwent diversion and 18 (56.2%) underwent restorative procedures. The median age was 49.5 years old for the diversion group and 23.5 years old for the reconstructive group (p = 0.001). The restorative surgery group was more likely to have an ASA 1-2 while the diversion group had a higher frequency of ASA 3-5 (p = 0.011). The median length of stay for the diversion surgery was 9.5 days and 5 days for the restoration group (p = 0.045). Complications occurred in 57% of patients in the diversion group and in 22% of patients in the restoration group (p = 0.049). There were otherwise no statistically significant differences in intraoperative data and postoperative complications. CONCLUSION: This is the first study using a national database to evaluate the surgical treatment of Hirschsprung's disease in adult patients. Complications are common and were more frequent in the older, sicker diversion group, with restoration of continuity being better tolerated in the younger, healthier patient population.

Transanal Endoscopic Microsurgery.

Transanal endoscopic microsurgery (TEM) was developed by Professor Gerhard Buess 30 years ago at the dawn of minimally invasive surgery. TEM utilizes a closed proctoscopic system whereby endoluminal surgery is accomplished with high-definition magnification, constant CO2 insufflation, and long-shafted instruments. The end result is a more precise excision and closure compared to conventional instrumentation. Virtually any benign lesion can be addressed with this technology; however, proper patient selection is paramount when using it for cancer.

Patient factors may predict anastomotic complications after rectal cancer surgery: Anastomotic complications in rectal cancer.

PURPOSE: Anastomotic complications following rectal cancer surgery occur with varying frequency. Preoperative radiation, BMI, and low anastomoses have been implicated as predictors in previous studies, but their definitive role is still under review. The objective of our study was to identify patient and operative factors that may be predictive of anastomotic complications. METHODS: A retrospective review was performed on patients who had sphincter-preservation surgery performed for rectal cancer at a tertiary medical center between 2005 and 2011. RESULTS: 123 patients were included in this study, mean age was 59 (26-86), 58% were male. There were 33 complications in 32 patients (27%). Stenosis was the most frequent complication (24 of 33). 11 patients required mechanical dilatation, and 4 had operative revision of the anastomosis. Leak or pelvic abscess were present in 9 patients (7.3%); 4 were explored, 2 were drained and 3 were managed conservatively. 4 patients had permanent colostomy created due to anastomotic complications. Laparoscopy approach, BMI, age, smoking and tumor distance from anal verge were not significantly associated with anastomotic complications. After a multivariate analysis chemoradiation was significantly associated with overall anastomotic complications (Wall = 0.35, p = 0.05), and hemoglobin levels were associated with anastomotic leak (Wald = 4.09, p = 0.04). CONCLUSION: Our study identifies preoperative anemia as possible risk factor for anastomotic leak and neoadjuvant chemoradiation may lead to increased risk of complications overall. Further prospective studies will help to elucidate these findings as well as identify amenable factors that may decrease risk of anastomotic complications after rectal cancer surgery.

Are our publications failing the inspection?: a review of the publications in rectal cancer surgery between 2002 and 2012.

BACKGROUND: Quality of publications is considered a subjective measurement, and more weight is placed on prospective studies, especially randomized clinical trials and meta-analyses. OBJECTIVE: This study describes the type of publications and evaluates the quality of randomized clinical trials and review articles using an objective measurement. DATA SOURCES: Medline (PubMed) is the data source for this work. STUDY SELECTION: We used the terms "rectal neoplasms/surgery" and the filters "10 years," "humans," and "English." MAIN OUTCOME MEASURES: We measured compliance with checklist items. Randomized clinical trials were reviewed using the Consolidates Standards of Reporting Trials statement; systematic reviews/meta-analyses were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: A total of 3603 articles were identified: 20.8% were case report/series, 20.5% were retrospective cohorts, 14.0% were reviews or meta-analyses, 16.4% were prospective cohorts, 14.0% were other types of articles (comments, letters, or editorials), 5.5% were clinical trials (phase I/II), 4.2% were randomized clinical trials, and 4.4% were cross-sectional studies. We reviewed 108 randomized clinical trials; the maximum score possible was 74.0, the average score was 44.6 (range, 20.0-64.0), 4 (3.7%) were graded as "excellent," 21 (19.4%) were "good," 44 (40.7%) were "deficient," and 39 (36.1%) were graded as "fail." The predictors of higher scores for randomized clinical trials were year of publication after 2007 (p = 0.00), higher impact factor (p = 0.03), and declared funding (p = 0.01). Twenty-nine meta-analyses were reviewed; the average score was 19.64 (range, 12.0-25.0); 5 articles (17.2%) were graded as "excellent," 12 (41.4%) were "good," 10 (34.5%) were "deficient," and 2 (6.9%) were "fail." LIMITATIONS: Only 1 electronic database was used, so we lacked a validated score. In addition, the search terms did not include "colorectal." CONCLUSIONS: A total of 20.8% of the articles published were case reports and 25.0% of the articles were prospective or clinical trials. Although randomized clinical trials and systematic reviews provide the highest level of evidence, publications with missing data limit replication of the study and affect the generalizability of results to other populations. To improve the quality of our publications, authors, reviewers, and journal editors should consider the endorsement of standardize checklists.

Recurrent retrorectal teratoma.

Retrorectal tumors are a rare group of neoplasms that occur most commonly in the neonatal and infant population. They vary in presentation, but teratomas are the most common and often present as a protruding mass from the sacrococcygeal region. Immediate surgical resection is indicated when found and coccygectomy is performed to prevent recurrence. When teratomas recur, the patients most often have vague symptoms and the tumors usually have malignant transformation. Here, we present the case of a young woman who underwent surgical resection of a sacrococcygeal teratoma at 3 days of age where the coccyx was not removed. She presented at 31 years of age with lower extremity paresthesias and radiography revealed a cystic mass extending from the sacrum. After resection, pathology revealed a recurrent teratoma with nests of adenocarcinoma.

What do patients think of medical students during their hospitalization? One institution's experience.

Multiple studies have shown patients have a positive attitude toward medical students in outpatient facilities, but it is unknown whether these results can be extrapolated to inpatients. The purpose of this study is to describe the patients' attitude toward medical students in the inpatient facility and factors that may affect it. A 43-item questionnaire was provided to patients of the general surgery department; it gathered demographics, clinical condition, and patients' opinions regarding the medical students' involvement in their care. Eighty-four patients completed the questionnaire. Forty-three per cent were males and the average age was 56 years old (range, 26 to 86 years). Sixty-one patients (72.6%) felt that having medical students enhanced the care provided. Patients' attitudes toward students were as follows: seven patients (8.3%) refused medical students, 40 (47.6%) accepted a limited involvement, and 37 (44%) offered no objections. Patients who refused medical students or preferred a limited involvement were more likely to 1) consider their health as good or excellent; 2) feel that the rounds were too early; and 3) feel that the residents did not spend enough time with them. More patients prefer that medical students have a limited involvement, especially when referring to minor procedures (e.g., nasogastric tube, intravenous line). Better more thorough communication with patients positively affects their attitudes toward students. More studies are required to confirm these results and to analyze other factors that may improve the patients' attitudes toward medical students.