Laparoscopic-Assisted Transgastric Endoscopic Retrograde Cholangiopancreatography With Placement of a Biliary Stent to Treat Traumatic Intrahepatic Bile Duct Disruption in a Patient With Roux-en-Y Gastric Bypass.

Hepatic injuries are common following blunt trauma and while frequently managed expectantly, biliary injury as a result of the trauma requires a high index of suspicion, a focused workup, and likely interventional treatment. A 44-year-old female with a history of Roux-en-Y gastric bypass presented after a ground level fall and was initially discharged home but represented with worsening abdominal pain and elevated liver enzymes. She was found to have a segment 5/6 biliary injury requiring laparoscopic-assisted transgastric endoscopic retrograde cholangiopancreatography with common bile duct stent placement. This case represents the difficulty of diagnosing biliary injuries following blunt trauma, and the need for advanced endoscopic interventions for treatment in patients with atypical anatomy.

Applying Evidence-based Principles to Guide Emergency Surgery in Older Adults.

Although outcomes for older adults undergoing elective surgery are generally comparable to younger patients, outcomes associated with emergency surgery are poor. These adverse outcomes are in part because of the physiologic changes associated with aging, increased odds of comorbidities in older adults, and a lower probability of presenting with classic "red flag" physical examination findings. Existing evidence-based perioperative best practice guidelines perform better for elective compared with emergency surgery; so, decision making for older adults undergoing emergency surgery can be challenging for surgeons and other clinicians and may rely on subjective experience. To aid surgical decision making, clinicians should assess premorbid functional status, evaluate for the presence of geriatric syndromes, and consider social determinants of health. Documentation of care preferences and a surrogate decision maker are critical. In discussing the risks and benefits of surgery, patient-centered narrative formats with inclusion of geriatric-specific outcomes are important. Use of risk calculators can be meaningful, although limitations exist. After surgery, daily evaluation for common postoperative complications should be considered, as well as early discharge planning and palliative care consultation, if appropriate. The role of the geriatrician in emergency surgery for older adults may vary based on the acuity of patient presentation, but perioperative consultation and comanagement are strongly recommended to optimize care delivery and patient outcomes.

Healthcare Disparity Education for Surgical Residents: Progress Made, More Needed.

BACKGROUND: Healthcare disparities are an important determinant of patient outcomes yet are not standardized within surgical resident education. This study aimed to determine the prevalence and design of current healthcare disparities curricula for surgical residents and included a resident-based needs assessment at a single institution. STUDY DESIGN: A national survey evaluating the presence and design of healthcare disparities curricula was distributed to general surgery program directors via the Association of Program Directors in Surgery Listserv. A related survey was administered to all general surgery residents at a single academic institution. RESULTS: One hundred forty-six program directors completed the survey, with 68 (47%) reporting an active curriculum. The most frequently taught topic is regarding patient race as a healthcare disparity, found in 63 (93%) of existing curricula. Fifty-two (76%) of the curricula were implemented within the last 3 years. Of the 78 (53%) programs without a curriculum, 8 (10%) program directors stated that their program would not benefit from one. Thirty-four (45%) of the programs without a curriculum cited institutional support and time as the most common barriers to implementation. Of the 23 residents who completed the survey, 100% desired learning practical knowledge regarding healthcare disparities relating to how race and socioeconomic status affect the clinical outcomes of surgical patients. CONCLUSIONS: Less than half of general surgery training programs have implemented healthcare disparities curricula. Resident preferences for the format and content of curricula may help inform program leaders and lead to comprehensive national standards.

Operative Management Considerations in a Patient With Multiple Occult Penetrating Cardiac Injuries.

Penetrating cardiac injury remains one of the deadliest traumatic injuries. Early identification and definitive operative management are critical tenets for patient survival; however, variable clinical presentations can obscure the diagnosis. Here, we present the case of a 58-year-old obese man who presented to an urban level 1 trauma center with multiple stab wounds to the epigastrium and lateral left chest in the axillary line with an unknown weapon. The patient was taken emergently to the operating room for exploratory laparotomy, median sternotomy, and attempted repair of multiple full-thickness lacerations of the right ventricle and left and right atrium. This case demonstrates several instructive points. First, a high index of suspicion for penetrating cardiac injury is needed, especially during triage of multiple injuries. Second, careful release of cardiac tamponade is critical. Finally, there are several indications for cardiopulmonary bypass, which include multichambered injuries, uncontrollable hemorrhage, and concern for intracardiac injury.

A Novel Educational Tool to Improve Medical Student Knowledge Acquisition During Surgical Rotations.

BACKGROUND: The addition of a novel education tool helps students improve understanding of general surgery topics. However, the effect of the new tool on objective exam performance is unknown. MATERIALS: A 10-item card of high-yield general surgery topics was implemented in the third-year surgery clerkship. Students reviewed these topics with general surgery residents. Scores from the National Board of Medical Examiners (NBME) surgery subject exam and Step 2 Clinical Knowledge (CK) board exam were compared among students who completed the Ask-a-Resident Topic card to a control group. RESULTS: Students who participated in the curriculum demonstrated significantly better scores on the NBME Surgery exam, t (236) = -2.56, P = .006. There was not a significant effect of the curriculum on Step 2 CK scores, although students who participated in the curriculum (M = 250.7, SD = 13.4) achieved higher scores than the control group (M = 247.8, SD = 14.2). DISCUSSION: The novel curriculum may improve objective student performance on standardized surgery exams.

The prevalence of pancreatic incidentalomas in patients undergoing surveillance for abdominal aortic aneurysms.

BACKGROUND: Serial imaging in patients with aortic aneurysms may identify non-vascular disease. However, the prevalence and clinical history of pancreatic incidentalomas in this population is unknown. METHODS: Retrospective cross-sectional study of adults who underwent computed tomography angiography (CTA) surveillance imaging for abdominal or thoracoabdominal aortic aneurysm at a single academic institution between 2015 and 2020. Descriptive statistics were used for patients with pancreatic lesions. RESULTS: Of 249 patients, 18 (7.2 %) had a pancreatic incidentaloma. Compared to patients without a lesion, those with a lesion were more likely female (50.0 % vs 24.2 %, p = 0.02) and less likely a smoker (72.2 % vs 90.0 %, p = 0.02). 3 patients with pancreatic lesions underwent intervention, and 1 patient received additional imaging. 2 patients had a surgical oncology referral. CONCLUSIONS: Pancreatic incidentalomas are common in patients with aortic aneurysm, but lesion characteristics and management vary. Results suggest that a multi-disciplinary approach, thorough documentation, and referral to pancreatic specialists may be warranted.

Enhancing Medical Student Education and Combating Mistreatment During a Surgery Clerkship With a Novel Educational Tool: A Pilot Study.

BACKGROUND: Medical education changes dramatically from preclinical to clinical years, and the learning environment becomes key as students strive to develop clinical competence and informed career decisions. This change becomes heightened on a surgical clerkship where student mistreatment is often perceived, and the fast-paced nature of surgery can result in limited resident-student interactions and time for examination preparation. OBJECTIVE: To evaluate medical student and resident perception of educational strategies during a surgical clerkship and to determine whether the addition of a novel educational tool would increase satisfaction with the surgical clerkship on examination preparation and team dynamics. SETTING: University of North Carolina at Chapel Hill, Department of Surgery. STUDY DESIGN: During the 2018-2019 academic year, a 10-item "Ask a Resident Topics" (ART) card of high yield general surgery topics was implemented as part of the third-year surgery clerkship curriculum. Students were asked to review a topic and then discuss it with a general surgery resident. They were expected to complete at least 6 of 10 topics by the end of the rotation for credit. At the end of the year, third-year medical students were administered a 23-item survey regarding their experience on the surgery clerkship and with the ART cards. Fourth-year medical students and those students at satellite sites who did not receive the ART cards were administered the same survey, minus specific questions about the ART card, and were used as a preintervention control. General surgery residents who participated in teaching were similarly surveyed. RESULTS: Of those students that completed the ART cards, 84% felt it improved their understanding of general surgery and were more likely to report the surgery clerkship prepared them well for the NBME examination compared to those who did not (Χ2 (1, N = 87) = 4.95, p = 0.03). They were also more likely to report residents were willing to discuss surgery topics with them (Χ2 (1, N = 87) = 2.77, p = 0.10). Seventy-three percent of students thought the card did not add undue stress to their clerkship. Sixty-three percent of all students felt they were a productive member of the surgery team, and this did not vary by intervention group (Χ2 (1, N = 87) = 0.03, p = 0.9). Students who completed the ART card were more likely to report being interested in surgery than those who did not (Χ2 (1, N = 87) = 4.20, p = 0.04). Hundred percent of residents surveyed felt the ART card provided value for themselves as a teacher and for the student as a learner. CONCLUSIONS: The ART card is mutually beneficial to both residents and medical students during the surgical clerkship. This tool is easy to implement, helps students improve their understanding of general surgery, increases camaraderie among the surgical team, and has a positive impact on students pursuing a career in surgery.

Delving deeper into disparity: The impact of health literacy on the surgical care of breast cancer patients.

BACKGROUND: Breast surgical oncology is a unique field that involves complex cancer management and longstanding patient interactions with the healthcare system, making it potentially challenging for patients with low health literacy. The purpose of this review is to summarize the current knowledge regarding health literacy in breast cancer and identify future directions for research and potential intervention in breast surgical oncology. DATA SOURCES: A search of relevant literature querying PubMed and Science Direct was performed and included the following keywords: health literacy, breast cancer, breast surgical oncology, surgery, outcomes, prevention, screening, healthcare utilization, chronic disease. CONCLUSIONS: Limited health literacy may detrimentally affect understanding and outcomes in breast surgical oncology. Identifying ways providers can improve patient understanding and utilization of health information is important, and surgeons may have a pivotal role. Further studies addressing health literacy in breast surgical oncology is needed in order to better optimize care of patients.

Aortic root replacement in a patient following congenital aortico-left ventricular tunnel repair in childhood.

Congenital aortico-left ventricular tunnel requires surgical repair during childhood. Long-term surveillance is essential in these patients given the risk for aortic aneurysm development in adulthood. We describe an aortic root replacement for an aortic aneurysm five decades following the closure of an aortic-left ventricular tunnel.

Endovascular Repair for Ruptured Abdominal Aortic Aneurysms has Improved Outcomes Compared to Open Surgical Repair.

INTRODUCTION: Ruptured abdominal aortic aneurysm (rAAA) remains a critical diagnosis, and research is needed to address outcomes following surgical repair. The purpose of this study was to compare nationwide outcomes for patients who received either endovascular repair (EVAR) or open surgical repair (OSAR) for rAAA. METHODS: The Medicare Provider Analysis and Review file from 2005 to 2009 was used to identify patients diagnosed with rAAA and treated with either EVAR or OSAR. Those patients with both procedures were excluded. Primary outcomes included mortality, postoperative complications, and readmission rates. Secondary outcomes included hospital resource utilization and length of stay (LOS). RESULTS: A total of 8480 patients with rAAA who underwent EVAR (n = 1939) or OSAR (n = 6541) were identified. On multivariate regression, the likelihood of dying in the hospital after OSAR compared to EVAR was significantly greater (odds ratio [OR] = 1.95; 95% confidence interval [CI] = 1.74-2.18). There was significantly greater frequency of postoperative complications after OSAR compared to EVAR (OR = 2.1, 95%CI = 1.86-2.37, P < .0001). Freedom from readmission after OSAR was significantly greater than that after EVAR. Total hospital cost for all services after EVAR was greater than that after OSAR (US$100 875 vs US$89 035; P < .0001), but intensive care unit (ICU) cost for EVAR was significantly less than that for OSAR (US$5516 vs US$8600; P < .0001). Total hospital and ICU LOS were shorter in EVAR compared to OSAR (P < .0001 for both). DISCUSSION: EVAR for rAAA has shown mortality benefits over OSAR as well as reduced ICU and total LOS. This data suggest EVAR is associated with a greater survival benefit, fewer postoperative complications, and may help improve hospital resource utilization.