Recognition and Surgical Management of Aberrant Right Hepatic Duct Originating From the Cystic Duct.

An aberrant right hepatic duct is a rare congenital anomaly of the biliary system. Failure to recognize these anomalies can result in serious complications. In this case, we present a patient who underwent laparoscopic cholecystectomy for chronic cholecystitis. Post-operatively she developed a bile leak for which she underwent reoperation. On re-exploration, she was discovered to have a cystic stump leak and a rare Hisatsugu type V anatomic anomaly of the right hepatic duct originating from the cystic duct. She was subsequently managed with oversewing of the cystic duct stump and drainage. This case demonstrates the importance of recognizing these rare anomalies and the challenges of management in a rural, resource-limited setting.

The quality of screening colonoscopy in rural and underserved areas.

BACKGROUND: Screening colonoscopy effectiveness depends on procedure quality; however, knowledge about colonoscopy quality in rural and underserved areas is limited. This study aimed to describe the characteristics and quality of colonoscopy and to examine predictors of colonoscopy quality at rural and underserved hospitals. METHODS: Adults undergoing colonoscopy from April 2017 to March 2019 at rural or underserved hospitals across the Illinois Surgical Quality Improvement Collaborative were prospectively identified. The primary outcome was colorectal adenoma detection, and secondary outcomes included bowel preparation adequacy, cecum photodocumentation, and withdrawal time. Performance was benchmarked against multisociety guidelines, and multivariable logistic regression was used to examine patient, physician, and procedure characteristics associated with adenoma detection. RESULTS: In total, 4217 colonoscopy procedures were performed at 8 hospitals, including 1865 screening examinations performed by 19 surgeons, 9 gastroenterologists, and 2 family practitioners. Physician screening volume ranged from 2 to 218 procedures (median 50; IQR 23-74). Adenoma detection occurred in 26.6% of screening procedures (target: ≥ 25%), 90.7% had adequate bowel preparation (target: ≥ 85%), 93.1% had cecum photodocumentation (target: ≥ 95%), and mean withdrawal time was 8.1 min (target: ≥ 6). Physician specialty was associated with adenoma detection (gastroenterologists: 36.9% vs. surgeons: 22.5%; OR 2.30, 95% CI 1.40-3.77), but adequate bowel preparation (OR 1.15, 95% CI 0.76-1.73) and cecum photodocumentation (OR 1.56, 95% CI 0.91-2.69) were not. CONCLUSION: Colonoscopies performed at rural and underserved hospitals meet many quality metrics; however, quality varied widely. As physicians are scarce in rural and underserved areas, individualized interventions to improve colonoscopy quality are needed.

Reap What You Sow: Which Rural Surgery Training Programs Currently Exist and Do Medical Students Know of Their Existence?

BACKGROUND: There exists an acute need to recruit and train general surgeons for rural communities. To assist medical students interested in rural surgery, the American College of Surgeons (ACS) website lists general surgery residencies, which are tailored to train the rural surgeon by providing exposure to endoscopy, gynecology, urology, orthopedics, and otolaryngology. Another available reference is the American Medical Association Fellowship and Residency Electronic Database (FREIDA). FREIDA allows programs to indicate availability of a rural training scheme. This is an effort to identify programs which demonstrate a commitment to training rural surgeons and evaluate accessibility of this information to medical students. METHODS: Each ACGME general surgery residency program in the United States and Canada received an electronic survey. They were queried on commitment to training rural surgeons and their ability to provide 3 to 12 months of subspecialty training. RESULTS: Of the 261 programs surveyed, 52 (19.9%) responses were obtained; 11 had established rural tracks and 15 were willing to customize a program. We identified 14 additional rural training programs not identified by either the ACS website or FREIDA. In total, 44 programs identified by ACS, FREIDA, and our survey indicate they can accommodate the rural surgical resident. CONCLUSIONS: For a medical student interested in rural surgery, several obstacles must be overcome to find the appropriate residency program. A complete and updated list of established tracks or customizable training schemes does not exist. Review of the ACS website and FREIDA online in addition to our survey has identified 44 of 261 (16.9%) ACGME accredited programs either with an existing rural surgical track or willing to customize their program accommodate a resident. To facilitate the recruitment of medical students into rural surgery, we support the maintenance of a complete and routinely updated list that identifies available training programs.