Eagle Syndrome Presenting after Blunt Trauma.

As classically described, Eagle syndrome is an entity where patients develop pain or neurologic manifestations arising from an elongated styloid process and/or an ossified stylohyoid ligament irritating or compressing adjacent cranial nerves or the carotid arteries. Over the past few years, there have been reports of actual injury to the internal carotid artery with dissection, occlusion, and strokes. We present 3 cases identified after blunt trauma: 1 due to carotid compression and 2 due to actual injury to the internal carotid artery. Eagle syndrome should be a consideration in any patient with a carotid injury due to blunt trauma or suffering a syncopal episode which led to blunt trauma. Carotid stenting is an effective treatment modality for injury to the carotid artery when anticoagulation is contraindicated. Styloidectomy is performed for symptoms due to carotid artery compression or if there is concern for future carotid injury from the styloid process.

ß-Blockade and Operative Mortality in Noncardiac Surgery: Harmful or Helpful?

IMPORTANCE: The use of perioperative pharmacologic ß-blockade in patients at low risk of myocardial ischemic events undergoing noncardiac surgery (NCS) is controversial because of the risk of stroke and hypotension. Published studies have not found a consistent benefit in this cohort. OBJECTIVE: To determine the effect of perioperative ß-blockade on patients undergoing NCS, particularly those with no risk factors. DESIGN, SETTING, AND PARTICIPANTS: This is a retrospective observational analysis of patients undergoing surgery in Veterans Affairs hospitals from October 1, 2008, through September 31, 2013. METHODS: ß-Blocker use was determined if a dose was ordered at any time between 8 hours before surgery and 24 hours postoperatively. Data from the Veterans Affairs electronic database included demographics, diagnosis and procedural codes, medications, perioperative laboratory values, and date of death. A 4-point cardiac risk score was calculated by assigning 1 point each for renal failure, coronary artery disease, diabetes mellitus, and surgery in a major body cavity. Previously validated linear regression models for all hospitalized acute care medical or surgical patients were used to calculate predicted mortality and then to calculate odds ratios (ORs). MAIN OUTCOMES AND MEASURES: The end point was 30-day surgical mortality. RESULTS: There were 326,489 patients in this cohort: 314,114 underwent NCS and 12,375 underwent cardiac surgery. ß-Blockade lowered the OR for mortality significantly in patients with 3 to 4 cardiac risk factors undergoing NCS (OR, 0.63; 95% CI, 0.43-0.93). It had no effect on patients with 1 to 2 risk factors. However, ß-blockade resulted in a significantly higher chance of death in patients (OR, 1.19; 95% CI, 1.06-1.35) with no risk factors undergoing NCS. CONCLUSIONS AND RELEVANCE: In this large series, ß-blockade appears to be beneficial perioperatively in patients with high cardiac risk undergoing NCS. However, the use of ß-blockers in patients with no cardiac risk factors undergoing NCS increased risk of death in this patient cohort.

The role of a preliminary PGY-3 in general surgery training.

INTRODUCTION: Even before the preliminary postgraduate year (PGY)-3 was eliminated from surgical residency, it had become increasingly difficult to fill general surgery PGY-4 vacancies. This ongoing need prompted the Association of Program Directors in Surgery (APDS) leadership to form a task force to study the possibility of requesting the restoration of the preliminary PGY-3 to Accreditation Council for Graduate Medical Education-approved general surgery residency programs. METHODS: The task force conducted a 10-year review of the APDS list serve to ascertain the number of advertised PGY-4 open positions. Following the review of the list serve, the task force sent IRB-approved electronic REDCap surveys to 249 program directors (PDs) in general surgery. RESULTS: The list serve review revealed more than 230 requests for fourth-year residents, a number that most likely underestimates the need, as such, vacancies are not always advertised through the APDS. A total of 119 PDs (~48%) responded. In the last 10 years, these 119 programs needed an average of 2 PGY-4 residents (range: 0-8), filled 1.3 positions (range: 0-7), and left a position unfilled 1.3 times (range: 0-7). Methods for finding PGY-4 residents included making personal contacts with other PDs (52), posting on the APDS Topica List Serve (47), and using the APDS Web site for interested candidates on residency and fellowship job listings (52). Reasons for needing a PGY-4 resident included residents leaving the program (82), extra laboratory years (39), remediation (31), and approved program expansion (21), as well as other issues. Satisfaction scores for the added PGY-4 residents were more negative (43) than positive (30). Problems ranged from lack of preparation to professionalism. When queried as to an optimal number of preliminary residents needed nationally at the PGY-3 level, responses varied from 0 to 50 (34 suggested 10). CONCLUSIONS: The survey of PDs supports the need for the reintroduction of a limited number of Accreditation Council for Graduate Medical Education-approved preliminary PGY-3 positions in general surgery residency programs.

Perceptions of graduating general surgery chief residents: are they confident in their training?

BACKGROUND: Debate exists within the surgical education community about whether 5 years is sufficient time to train a general surgeon, whether graduating chief residents are confident in their skills, why residents choose to do fellowships, and the scope of general surgery practice today. STUDY DESIGN: In May 2013, a 16-question online survey was sent to every general surgery program director in the United States for dissemination to each graduating chief resident (CR). RESULTS: Of the 297 surveys returned, 76% of CRs trained at university programs, 81% trained at 5-year programs, and 28% were going directly into general surgery practice. The 77% of CRs who had done >950 cases were significantly more comfortable than those who had done less (p < 0.0001). Only a few CRs were uncomfortable performing a laparoscopic colectomy (7%) or a colonoscopy (6%), and 80% were comfortable being on call at a Level I trauma center. Compared with other procedures, CRs were most uncomfortable with open common bile duct explorations (27%), pancreaticoduodenectomies (38%), hepatic lobectomies (48%), and esophagectomies (60%) (p < 0.00001). Of those going into fellowships, 67% said they truly had an interest in that specialty and only 7% said it was because they were not confident in their surgical skills. CONCLUSIONS: Current graduates of general surgery residencies appear to be confident in their skills, including care of the trauma patient. Fellowships are being chosen primarily because of an interest in the subspecialty. General surgery residency no longer provides adequate training in esophageal or hepatopancreatobiliary surgery.

Percutaneous femoral vein access for inferior vena cava filter placement does not cause insertion-site thrombosis.

BACKGROUND: The efficacy of inferior vena cava (IVC) filters in the prevention of pulmonary embolism in patients with lower extremity deep venous thrombosis (DVT) has been well described. What remains uncertain is the risk of insertion-site thrombosis of the femoral vein after filter placement. Historically, the risk was relatively high, most likely due to large delivery systems and therefore a need for longer compression at the insertion site to provide hemostasis. The purpose of this prospective study was to determine the incidence of thrombus formation at the femoral vein puncture site after percutaneous insertion of contemporary IVC filters. METHODS: From October 2010 to November 2011, 61 consecutive patients underwent placement of an IVC filter by 3 vascular surgeons and 3 interventional radiologists at our tertiary-care Level I trauma center. All filters were inserted through the right or left common femoral vein. Duplex ultrasound studies (DUS) were performed within 24 hours before filter placement and 24‒72 hours after filter placement. RESULTS: Fifty-six patients completed the study, including 46 men and 10 women. They ranged in age from 19 to 90 (mean 50) years. Forty-one filters (73%) were placed for prophylaxis: 39 of the patients were trauma victims with immobility and/or contraindications to anticoagulation, 1 had an intracranial hemorrhage with an underlying malignancy, and 1 had very limited mobility. The remaining 15 filters (27%) were placed because of an acute DVT with a contraindication to or a complication from anticoagulation. The filters utilized were: Boston Scientific-Greenfield (n=25); Cook-Celect (n=18); Bard-G2X (n=2); Bard-Eclipse (n=6); and Cordis-TrapEase (n=5). Sheath diameters ranged from 6- to 12-French. None of the 56 patients had thrombus formation at the insertion site on follow-up DUS. CONCLUSIONS: Based on our study findings, the risk of femoral insertion-site thrombosis after percutaneous placement of contemporary IVC filters is negligible. Concern for femoral vein thrombosis should not be a reason for using the internal jugular vein to deploy IVC filters.

General surgery vs fellowship: the role of the Independent Academic Medical Center.

OBJECTIVES: To compare career choices of residency graduates from Independent Academic Medical Center (IAMC) and University Academic Medical Center (UAMC) programs and evaluate program directors' perceptions of residents' motivations for pursuing general surgery or fellowships. DESIGN: From May to August 2011, an electronic survey collected information on program characteristics, graduates' career pursuits, and career motivations. Fisher's exact tests were calculated to compare responses by program type. Multivariate logistic regression was used to identify independent program characteristics associated with graduates pursuing general surgery. SETTING: Data were collected on graduates over 3 years (2009-2011). PARTICIPANTS: Surgery residency program directors. RESULTS: Seventy-four program directors completed the survey; 42% represented IAMCs. IAMCs reported more graduates choosing general surgery. Over one-quarter of graduates pursued general surgery from 52% of IAMC vs 37% of UAMC programs (p = 0.243). Career choices varied significantly by region: over one-quarter of graduates pursue general surgery from 78% of Western, 60% of Midwestern, 40% of Southern, and 24% of Northeastern programs (p = 0.018). On multivariate analysis, IAMC programs were independently associated with more graduates choosing general surgery (p = 0.017), after adjustment for other program characteristics. Seventy-five percent of UAMC programs reported over three-fourths of graduates receive first choice fellowship, compared with only 52% of IAMC programs (p = 0.067). Fellowships were comparable among IAMC and UAMC programs, most commonly MIS/Bariatric (16%), Critical Care/Trauma (16%), and Vascular (14%). IAMC and UAMC program directors cite similar reasons for graduate career choices. CONCLUSIONS: Most general surgery residents undergo fellowship training. Graduates from IAMC and UAMC programs pursue similar specialties, but UAMC programs report more first choice acceptance. IAMC programs may graduate proportionately more general surgeons. Further studies directly evaluating surgical residents' career choices are warranted to understand the influence of independent and university programs in shaping these choices and to develop strategies for reducing the general surgeon shortage.

Vena cava filter practices of a regional vascular surgery society.

BACKGROUND: Vena cava filter (VCF) use in the United States has increased dramatically with prophylactic indications for placement and the availability of low-profile retrievable devices, which are overtaking the filter market. We surveyed the practice patterns of a large group of vascular surgeons from a regional vascular surgery society to see whether they mirrored current national trends. METHODS: A 17-question online VCF survey was offered to all members of the Southern Association of Vascular Surgery. The responses were analyzed using the χ(2) goodness of fit tests. RESULTS: Of the 276 members surveyed, 126 (46%) responded, with 118 (93%) indicating that they placed filters during their practice. Highly significant differences were identified with each question (at least P < 0.002). Regarding the inferior vena cava, the preferred permanent filters were the Greenfield (31%), the TrapEase (15%), the Vena Tech (5%), and a variety of retrievable devices (49%). Fifty percent of the respondents placed retrievable filters selectively; 26% always placed them; and 24% never did. Filters were placed for prophylactic indications <50% of the time by 63% of the respondents. Overall, retrievable filters (when not used as permanent filters) were removed <25% of the time by 64% of the respondents and <50% of the time by 78% of the respondents. The femoral vein was the preferred access site for 84% of the respondents. Major complications were few but included filter migration to the atrium (one), atrial perforation (one), abdominal pain requiring surgical filter removal (two), inferior vena cava thrombosis (12 vena cava thrombosis--4 due to TrapEase filters), strut fracture with embolization to heart or lungs (three Bard retrievable filters), and severe tilting precluding percutaneous retrieval and protection from pulmonary emboli (8 filters with severe tilt--7 of which were Bard). Of the respondents, 59% had never placed a superior vena cava filter, and 28% had placed five or fewer. CONCLUSIONS: Although VCF insertion overall appears safe, some complications are specific to biconical and certain retrievable filters. Given the low removal rate and lack of long-term experience with retrievable filters, routine use of these devices as permanent filters should be questioned. If used on a temporary basis, there should be a plan for filter removal at the time of implantation.

Retrospective evaluation of residents' American Board of Surgery In-Service Training Examination (ABSITE) scores as a tool to evaluate changes made in a basic science curriculum.

OBJECTIVE: To evaluate the effectiveness of a new basic science curriculum at a university-affiliated general surgery residency program. DESIGN: A retrospective evaluation of general surgery residents' American Board of Surgery (ABS) In-Training Examination (ABSITE) scores before and after the implementation of a new basic science curriculum. SETTING: Not-for-profit tertiary referral center with a university-affiliated Accreditation Council for Graduate Medical Education (ACGME) accredited community general surgery residency program. PARTICIPANTS: Postgraduate year (PGY) 1 through 5 general surgical residents. RESULTS: The total questions answered correctly (percent correct) in the main 3 categories improved after implementation of the new curriculum for PGY 1 (total test: 70 +/- 7 vs 60 +/- 9, p < 0.05; clinical science: 71 +/- 10 vs 59 +/- 9, p < 0.05; and basic science: 69 +/- 7 vs 60 +/- 10, p = 0.0003) and for PGY 2 residents (total test: 74 +/- 5 vs 66 +/- 7, p < 0.05; clinical science: 74 +/- 7 vs 66 +/- 8, p = 0.003; and basic science: 74 +/- 5 vs 66 +/- 8, p < 0.05). With the exception of the percentage of clinical questions answered correctly for the PGY 4 level, there was no statistically significant worsening of scores in any other subcategories for any other PGY levels (3 through 5) after implementation of the new program. Before the institution of the new curriculum, 24% (26/110) of residents scored below the 35th percentile, and after the institution of the new curriculum, this number decreased to 12% (12/98), p = 0.006. The first-time passage rate on the ABS Qualifying Examination was unchanged in the period before and after the implementation of the new curriculum (89% vs 86%; p = 0.08). When comparing the bimonthly quizzes with the ABSITE, the correlation coefficient was 0.34. CONCLUSION: After the implementation of a new basic science curriculum organized and directed by the faculty, there were statistically significant improvements of PGY 1 and 2 residents' ABSITE scores.

Cerebral oximetry does not correlate with electroencephalography and somatosensory evoked potentials in determining the need for shunting during carotid endarterectomy.

OBJECTIVE: Several reports in the literature have described the value of regional cerebral oximetry (rSO(2)) as a neuromonitoring device during carotid endarterectomy (CEA). The use of rSO(2) is enticing because it is simpler and less expensive than other neuromonitoring modalities. This study was performed to compare the efficacy of rSO(2) with electroencephalography (EEG) and median nerve somatosensory evoked potentials (SSEP) in determining when to place a shunt during CEA. METHODS: From October 2000 to June 2006, 323 CEAs were performed under general anesthesia by six surgeons. Shunting was done selectively on the basis of EEG and SSEP monitoring under the auspices of an intraoperative neurophysiologist. All patients were retrospectively reviewed to see if significant discrepancies existed between EEG/SSEP and rSO(2). RESULTS: Twenty-four patients (7.4%) showed significant discrepancies. Sixteen patients showed no significant EEG/SSEP changes, but profound changes occurred in rSO(2), and no shunt was placed. In seven patients there was no change in rSO(2) but a profound change occurred in EEG/SSEP, and shunts were placed. In one patient early in the series, the EEG and SSEP were unchanged but the rSO(2) dropped precipitously, and a shunt was placed. In the 299 patients who showed no discrepancies, 285 were not shunted and 14 required a shunt. Two strokes occurred in the entire series (0.6%), none intraoperatively. Shunts were placed in 23 patients (7%). The sensitivity of rSO(2) compared with EEG/SSEP was 68%, and the specificity was 94%. This gave a positive-predictive value of 47% and a negative-predictive value of 98%. CONCLUSIONS: Relying on rSO(2) alone for selective shunting is potentially dangerous and might have led to intraoperative ischemic strokes in seven patients and the unnecessary use of shunts in at least 16 patients in this series. The use of rSO(2) adds nothing to the information already provided by EEG and SSEP in determining when to place a shunt during CEA.