The impact of burnout syndrome on practitioners working within rural healthcare systems.

INTRODUCTION: Burnout syndrome (BOS) affects up to 50% of healthcare practitioners. Limited data exist on BOS in paramedics/firstresponders, or others whose practice involves trauma. We sought to assess the impact of BOS in practitioners of rural healthcare systems involved in the provision of trauma care within West Virginia. METHODS: A 3-part survey was distributed at two regional trauma conferences in 2018. The survey consisted of 1) Demographic/occupational items, 2) The Mini Z Burnout Survey, and 3) elements measuring the impact, and supportive infrastructure to prevent and/or manage BOS. RESULTS: Response rate was 74.7% (127/170 attendees). Respondents included emergency medical services (EMS) (44.9%), nurses (37.8%), and physicians (9.4%). Overall, 31% reported BOS - physicians (45.5%), EMS (35.1%), and nurses (25.0%). Most agreed that BOS impacts the health of medical professionals (99.2%) and presents a barrier to patient care (97.6%). Those with BOS reported higher stress (p < 0.001), chaos at work (p < 0.001), and excessive documentation time at home (p < 0.001). Fewer respondents with BOS reported job satisfaction (p < 0.001), control over workload (p = 0.001), sufficient time for documentation (p ≤0.001), value alignment with institutional leadership (p = 0.001), and team efficiency (p = 0.004). Unique factors for BOS in EMS included: lack of control over workload (p = 0.032), poor value alignment with employer (p = 0.002), lack of efficient teamwork (p = 0.006), and excessive time documenting at home (p = 0.003). CONCLUSIONS: Burnout syndrome impacts rural healthcare practitioners, regardless of discipline. These data highlight a need to address the entire team and implement occupation-specific approaches for prevention and treatment. Further prospective study of these findings is warranted.

Ventral Hernia Management: Expert Consensus Guided by Systematic Review.

OBJECTIVE: To achieve consensus on the best practices in the management of ventral hernias (VH). BACKGROUND: Management patterns for VH are heterogeneous, often with little supporting evidence or correlation with existing evidence. METHODS: A systematic review identified the highest level of evidence available for each topic. A panel of expert hernia-surgeons was assembled. Email questionnaires, evidence review, panel discussion, and iterative voting was performed. Consensus was when all experts agreed on a management strategy. RESULTS: Experts agreed that complications with VH repair (VHR) increase in obese patients (grade A), current smokers (grade A), and patients with glycosylated hemoglobin (HbA1C) ≥ 6.5% (grade B). Elective VHR was not recommended for patients with BMI ≥ 50 kg/m (grade C), current smokers (grade A), or patients with HbA1C ≥ 8.0% (grade B). Patients with BMI= 30-50 kg/m or HbA1C = 6.5-8.0% require individualized interventions to reduce surgical risk (grade C, grade B). Nonoperative management was considered to have a low-risk of short-term morbidity (grade C). Mesh reinforcement was recommended for repair of hernias ≥ 2 cm (grade A). There were several areas where high-quality data were limited, and no consensus could be reached, including mesh type, component separation technique, and management of complex patients. CONCLUSIONS: Although there was consensus, supported by grade A-C evidence, on patient selection, the safety of short-term nonoperative management, and mesh reinforcement, among experts; there was limited evidence and broad variability in practice patterns in all other areas of practice. The lack of strong evidence and expert consensus on these topics has identified gaps in knowledge where there is need of further evidence.

Benign mesothelial mesenteric cyst: case report and literature review.

A rare case of a benign mesothelial cyst arising from the mesentery of the descending colon is presented. A 73 year old female presented with an asymptomatic mesenteric cyst on CT scan. Colonoscopy revealed extrinsic compression of the descending colon. Surgical resection of the cyst necessitated partial colon resection due to the adherent nature of the cyst to the colon and its mesentery. The details of the case are presented as well as a brief review of the relevant literature.

Identification of the sentinel node by ultrasonography in patients with breast cancer.

BACKGROUND: Identification of the sentinel node (SN) in patients with breast cancer is done by tracking a radioactive tracer, a vital dye, or both, as the marker(s) reach the axilla. Replacing this method with ultrasonographic (US) recognition of the SN could eventually spare patients the need for systemic anesthesia, permit minimally invasive outpatient biopsy of the node, and allow the formulation of a precise therapeutic plan before a definitive surgical procedure. METHODS: Eighty-eight axillae of 84 patients with a histologic diagnosis of breast cancer were studied by injecting the subareolar area of the affected breast(s) with technetium 99 and an iron preparation before the planned surgical procedure and SN biopsy. An axillary US scan was performed in all patients before the injection of the markers. After induction of anesthesia, the SN was identified, needle-localized, and extracted under US guidance. Confirmation that the SN was retrieved was established by concordance with the audible gamma signal, unless there was none. All extracted nodes had iron stains performed. RESULTS: All except three of the SNs were identified with US after the iron marker was injected, and all except six were identified by their radioactive signal. One of the SNs undetected on US was identified by its radioactive tracer, and the other two, although seen on US, had neither a gamma signal nor concordant iron deposits. All other SNs identified with US had a concordant audible signal when there was one, and all had concordant iron deposits on microscopy. Of the six SNs without a gamma signal, three without preincision activity were identified with US; three with neither a preincision nor an ex vivo signal were seen with US, but two of these were the SNs without a concordant iron deposit. CONCLUSIONS: Using an iron preparation, the SN in patients with breast cancer can be identified with US with an accuracy equal to and perhaps better than that achieved with a radioactive tracer. These findings may change the current diagnostic model and affect the therapeutic algorithm of breast cancer patients.

Splenic artery embolization for the treatment of bleeding gastric varices secondary to splenic vein thrombosis.

Splenic vein thrombosis can lead to gastric varices. Subsequent upper gastrointestinal bleeding may ensue related to the change in venous outflow to the portal system. Vascular surgeons are infrequently asked to assist in the management of this entity. However, with many vascular surgeons providing diverse endovascular-based interventions, understanding catheter-based solutions is imperative. This report presents a case in which arterial embolization was used to treat gastric variceal bleeding.

Cutaneous metastasis of colon cancer: case report and literature review.

Cutaneous metastases arising from an internal malignancy are a rare phenomenon, occurring in 0.001% of all skin biopsies performed. Of these, 6.5% originate from the a primary colon cancer. Colon cancer, when metastatic to the skin, typically appears as a painless flesh-colored nodule or as a mass with occasional ulceration. We report a case of a large cutaneous metastasis to the suprascapular region as the initial presenting symptom of an underlying colon cancer.

Streptococcus bovis bacteremia as the initial presentation of carcinoma of the gallbladder.

There is a well known association between Streptococcus bovis infection and the presence of a coexisting colonic adenocarcinoma. Association of S. bovis with other malignancies has only been rarely reported. We report a 77-year-old male who presented with with Streptococcus bovis bacteremia in the setting of acute cholecystitis. Given the association of colon adenocarcinoma and Streptococcus bovis bacteremia, colonoscopy was performed prior to cholecystectomy to evaluate a possible coexisting colon neoplasm, which was negative. At cholecystectomy, the patient was found to have a carcinoma of the gallbladder, which was treated with radical cholecystectomy and periportal lymphadenectomy. This is the first case of Streptococcus bovis infection and coexisting gallbladder cancer to be reported, and highlights the need for maintenance of a high index of suspicion for malignancies other than colon cancer when patients present with Streptococcus bovis bacteremia.

Building clinic programs that drive a department of surgery's strategic plan.

Effectively navigating and executing change within a medical organization, particularly a large health care enterprise, such as a department of surgery within a major hospital system, can present a major challenge to both departmental and institutional leadership. In developing projects designed to bring about desired change, it is essential to be mindful of the strategic plan of the institution and department and to design change initiatives to create models that align with and serve to enhance both the institutional and departmental missions. Doing so requires careful definition of the mission and vision of the department and the key stakeholders within the institution; defining both short- and long-term goals; critical analysis of resources, needs, strengths, and weaknesses; and maintaining a clear understanding of the goals, expectations, and specific measures of success. A careful project design process should then follow before implementation. In the following paragraphs, some of the key considerations and challenges of this process are explored in the particular context of developing clinics and clinical services in such a manner that the departmental and institutional missions are well-supported and advanced.

Biliary Dyskinesia-Controversies, Diagnosis, and Management: A Review.

Importance: Biliary dyskinesia is a disorder characterized by biliary pain, a sonographically normal gallbladder, and a reduced gallbladder ejection fraction on cholecystokinin-cholescintigraphy (CCK-HIDA) scan. Laparoscopic cholecystectomy remains a common treatment for biliary dyskinesia despite a lack of high-quality evidence supporting the practice. The following review summarizes the current biliary dyskinesia outcomes data, the diagnostic strategies and their limitations, biliary dyskinesia in the pediatric population, the emerging phenomenon of the hyperkinetic gallbladder, and suggestions for addressing identified knowledge gaps. Observations: The majority of studies on the topic are retrospective, with wide variations in inclusion criteria and definition of biliary pain. Most report a very short follow-up interval, often a single office visit, with variable and nonstandardized definitions of a satisfactory outcome. Despite a published Society of Nuclear Medicine guideline for its performance, CCK-HIDA scan protocols vary among institutions, which has led to considerable variability in the consistency and reproducibility of CCK-HIDA results. The few prospective studies available, although small and heterogeneous, support a role for cholecystectomy in the treatment of adult biliary dyskinesia. Despite these knowledge gaps, biliary dyskinesia is now the number 1 indication for cholecystectomy in children. Cholecystectomy for the hyperkinetic gallbladder appears to be an emerging phenomenon, despite, as in biliary dyskinesia, a lack of quality data supporting this practice. Randomized trials addressing these gaps are needed but have been difficult to conduct owing to strong clinician and patient bias toward surgery and the lack of a criterion-standard nonsurgical treatment for the control arm. Conclusions and Relevance: The use of cholecystectomy for adult biliary dyskinesia is reasonable based on the available data. Insufficient data exist regarding laparoscopic cholecystectomy for pediatric dyskinesia and the hyperkinetic gallbladder population. Large-scale prospective studies, either randomized trials or large prospectively followed cohort studies, are needed to address the knowledge gaps surrounding this controversial diagnosis.

Race/Ethnicity and Social Determinants of Health and Their Impact on Receiving Appropriate Chemotherapy for Colon Cancer.

INTRODUCTION: Despite the heightened understanding and improved treatment for colorectal cancer in the United States, social determinants of health (SDH) play a significant role in the colorectal cancer outcomes. We sought to investigate the relationship between SDH and appropriate utilization of adjuvant chemotherapy in stage III colon cancer. METHODS: For this retrospective study, we utilized data from the National Cancer Data Base (NCDB). Descriptive statistics are reported, including means and 95% confidence intervals for continuous variables and frequency and proportions for categorical variables. Univariate hypothesis testing to identify categorical level factors associated with treatment used Wilcoxon rank sum or Kruskal-Wallis tests, with multivariate analyses performed using regression analysis. RESULTS: Significant differences were as follows: Metro-non-Hispanic White patients received treatment less frequently (69.7%) when compared to Metro-non-Hispanic Black patients (73.4%) (P < .001). Increasing age was a negative predictor of likelihood to receive with those over 65 years old having an 83% decrease in likelihood to receive chemotherapy when compared to those under 65 (P < .001). Medicaid patients were 47% less likely and Medicare patients were 40% less likely to receive chemotherapy when compared to those with private insurance (P < .001). Rural patients were statistically more likely to receive chemotherapy (OR 1.42, 1.32-2.52, P < .001) as were urban patients, (OR 1.26, 1.20-1.31, P < .001) when compared to patients residing in metro areas. CONCLUSION: Age, living in a Metro area, and government insurance status at diagnosis are negatively correlated with the likelihood of receiving chemotherapy. Race was not associated with differences in receiving chemotherapy.

Race/Ethnicity and Social Determinants of Health and Their Impact on the Timely Receipt of Appropriate Operative Treatment of Colon Cancer.

INTRODUCTION: Rates of appropriate surgical treatment of colon cancer are historically worse in traditionally marginalized populations. We sought to examine which social determinants of health may be associated with longer time to appropriate operative intervention. METHODS: The National Cancer Databank was queried for this retrospective study. Adult patients (18 to 90 years of age) diagnosed between 2004 and 2018 with single or primary, stage III colon cancer were included. Patient demographic variables included age at diagnosis, sex, ethnicity (Hispanic or non-Hispanic), comorbidity score, median household income, education status, rural/urban status, treatment facility type and location, and insurance status. Disease characteristics include stage (stage 3), primary site, surgical margins, tumor size, and number of nodes resected. Reported descriptive statistics include means and 95% confidence intervals for continuous variables and frequency and proportions for categorical variables. Univariate and multivariate analyses were performed. RESULTS: A total of 134,601 individuals diagnosed with stage 3 colon cancer were included. Time to surgery in all cases had a mean of 26.4 ± 19.0 days. Multivariate analysis of time to surgery indicated that receiving surgery at a Community Cancer Program, Charlson-Deyo Score of 0, younger age, and non-Hispanic-White race/ethnicity are associated with decreased time to surgery (P < .001). CONCLUSION: Patients who receive surgery at a Community Cancer Program, have fewer comorbidities, have lower household income, are younger, and receive surgery within 50 miles of their primary residence are more likely to have timely surgery.

Ten-Year Review of Tracheostomy Techniques and Related Complications.

BACKGROUND: Tracheostomy is a frequently performed procedure that allows for definitive airway access in critically ill patients. Complications associated with tracheostomy have been well documented in the literature. This study aims to examine if different tracheostomy techniques were associated with specific complications. Secondary objectives were to determine the rate and commonality of post-tracheostomy complications. METHODS: This was a descriptive retrospective study of patients who underwent tracheostomy between June 2009 and June 2019. Patients included in the study were ≥18 years and were admitted to a rural tertiary care hospital system. RESULTS: Overall procedure complication rate was 34.3% with pneumonia (18.6%), obstruction (6.2%), bleeding (4.0%), and accidental tube decannulation (3.8%) being the most common. Rate of complications was not associated with the timing of the tracheostomy, the incision type, tube location, tracheostomy technique, and securing technique. However, tube size significantly differed between patients with or without complications (P = .016). Tube size 8 Shiley was most commonly used in both groups and was significantly associated with reduced complication rate (72.0% vs 78.8%, P = .002). CONCLUSION: Tracheostomy technique should be guided by proceduralist experience and patient clinical picture to determine the best approach. However, the association of post-tracheostomy complication with tube size perhaps will guide clinicians with tube size selection.

Southeastern Surgical Congress Presidential Address: "Finding Your Own Unique Place Within the House of Surgery".

The term the "House of Surgery" is often used in conversation, but the origin of the phrase is not well known to most. In the following article, the origin of the phrase is explained, as is its relevance to the maintenance of a strong surgical community in today's world. In addition, examples are provided as to how each surgeon can find their own unique role in the House of Surgery, with the goal being to increase understanding and collaboration tween surgeons in all types of practice settings.

Elective robotic partial colon and rectal resections: series of 170 consecutive robot procedures involving the Da Vinci Xi robot by a community general surgeon.

Robotic colorectal procedures may overcome the disadvantages of laparoscopic surgery. While the literature has multiple studies from specialized centers, experience from general surgeons is minimal. The purpose of this case series is to review elective partial colon and rectal resections by a general surgeon. 170 consecutive elective partial colon and rectal resections were reviewed. The cases were analyzed by type of procedure and total cases. The outcomes analyzed were procedure time, conversion rate, length of stay, complications, anastomotic leak, and node retrieval in the cancer cases. There were 71 right colon resections, 13 left colon resections, 44 sigmoid colon resection sand 42 low anterior resections performed. The mean length of procedure was 149 min. The conversion rate was 2.4%. The mean length of stay was 3.5 days. The percentage of cases one or more complications was 8.2%. There were 3 anastomotic leaks out of 159 anastomoses (1.9%). The mean lymph node retrieval was 28.4 for the 96 cancer cases. Robot partial colon and rectal resections on the Da Vinci Xi robot can be completed safely and efficiently by a community general surgeon. Prospective studies are needed to demonstrate reproducibility by community surgeons performing robot colon resections.

Genetic Considerations in the Tumorigenesis, Diagnosis, and Treatment of Differentiated Thyroid Cancer: Current State of the Science.

Thyroid nodules remain a common diagnosis encountered in general and endocrine surgical practice, and thyroid cancer appears to be increasing in incidence in both the United States and worldwide. The understanding of the complex genetics surrounding thyroid neoplasia has increased substantially in recent years and, consequently, has become a consideration in risk stratification, diagnosis, prognosis, and treatment. Molecular genetic analysis of thyroid nodules is now a readily available technology for diagnostic purposes via analysis of fine-needle aspiration biopsy (FNAB) specimens. Although their routine use is controversial, they may aid in selecting which patients require surgery and those who may be safely observed. In the following review, the genetics of the tumorigenesis of thyroid cancer are reviewed, focusing on the most common and clinically relevant of the literally hundreds of known mutations. Following this, the current status of the use of genetic analysis and molecular diagnostics in the workup of thyroid nodules and the diagnosis of differentiated thyroid cancer is explored. Finally, evolving concepts relating to the use of thyroid cancer genetics in individualizing treatment planning, follow-up, and management of recurrent disease is discussed. The goal is to provide the general surgeon with a working knowledge of the most common genetic alterations present in differentiated thyroid cancer, their relevance in clinical practice, and how they impact prognosis and treatment.

A Comparison of Component Separation With Porcine Acellular Dermal Reinforcement to Bovine Acellular Dermal Matrix in the Repair of Significant Midline Ventral Hernia Defects.

BACKGROUND: The optimal material for reinforcement of complex abdominal ventral hernia repair (VHR) remains controversial. Biologic prostheses such as porcine and bovine acellular dermal matrix (PADM/BADM) have shown favorable results, but few head-to-head comparisons between the two types exist. We sought to provide such a comparison. METHODS: We performed a retrospective cohort study comparing 40 consecutive patients who underwent open component separation (CS/VHR) with PADM reinforcement to 39 consecutive patients who underwent open CS/VHR with BADM reinforcement at our institution. Patient characteristics, outcomes, complications, reoperations, and hernia recurrences were obtained by chart review. Fisher's exact and t-test analyses compared patient characteristics and outcomes between the 2 cohorts. Statistical significance was set as P < .05. RESULTS: Patient groups did not differ significantly in race (P=.36), age (P=.8), BMI (P=.34), sex (P=.09), steroid usage (p-1.00), COPD (P=.43), number of previous abdominal operations (P=.66), and duration of follow-up (P=.65). There were significantly more smokers in the PADM group (37.5% vs 12.8%, P=.01). Mean defect size was significantly greater in the PADM group (372.5 cm2 vs 292. cm2 in the BADM group, P=.001) as was the number of Ventral Hernia Working Group (VHWG) grade III/IV hernias (65.0% vs 38.4%, P=.02). Recurrence rates were lower in the BADM group, (12.5% vs 5.1%, P=.26), as was recurrence or complications requiring reoperation (17.5% vs 5.1%, P=.15). Postoperative wound events were also significantly lower in the BADM group (30.0% vs 2.6%, P=.001). CONCLUSIONS: In our series, CS/BADM was associated with significantly fewer wound complications. Recurrences and complications requiring reoperation were also fewer, which trended toward but did not reach statistical significance, presumably due to the small sample size. These findings indicating superiority of BADM over PADM are potentially confounded by the higher percentage of smokers, the larger mean defect size, and the higher number of VHWG III/IV patients in the PADM group. Further prospective study of these findings is warranted.

The Intersection of Race and Rurality and its Effect on Colorectal Cancer Survival.

INTRODUCTION: Outcomes in colorectal cancer treatment are historically worse in Black people and residents of rural areas. Purported reasons include factors such as systemic racism, poverty, lack of access to care, and social determinants of health. We sought to determine whether outcomes worsened when race and rural residence intersected. METHODS: The National Cancer Database was queried for individuals with stage II-III colorectal cancer (2004-2018). To examine the intersectionality of race/rurality on outcomes, race (Black/White) and rurality (based on county) were combined into a single variable. Main outcome of interest was 5-year survival. Cox hazard regression analysis was performed to determine variables independently associating with survival. Control variables included age at diagnosis, sex, race, Charlson-Deyo score, insurance status, stage, and facility type. RESULTS: Of 463 948 patients, 5717 were Black-Rural, 50 742 were Black-Urban, 72 241 were White-Rural, and 33 5271 were White-Urban. Five-year mortality rate was 31.6%. Univariate Kaplan-Meier survival analysis demonstrated race-rurality was associated with overall survival (P < .001), with White-Urban having the greatest mean survival length (47.9 months) and Black-Rural with the lowest (46.7 months). Multivariable analysis found that Black-Rural (1.26, 95% confidence interval [1.20-1.32]), Black-Urban (1.16, [1.16-1.18]), and White-Rural (HR: 1.05; (1.04-1.07) had increased mortality when compared to White-Urban individuals (P < .001). CONCLUSION: Although White-Rural individuals fared worse than White-Urban, Black individuals fared worst of all, with the poorest outcomes observed in Black individuals in rural areas. This suggests that both Black race and rurality negatively affect survival, and act synergistically to further worsen outcomes.

Clinical and Socioeconomic Factors that Predict Non-completion of Adjuvant Chemotherapy for Colorectal Cancer in a Rural Cancer Center.

BACKGROUND: Previous literature demonstrates correlations between comorbidities and failure to complete adjuvant chemotherapy. Frailty and socioeconomic disparities have also been implicated in affecting cancer treatment outcomes. This study examines the effect of demographics, comorbidities, frailty, and socioeconomic status on chemotherapy completion rates in colorectal cancer patients. METHODS: This was an observational case-control study using retrospective data from Stage II and III colorectal cancer patients offered chemotherapy between January 01, 2013 and January 01, 2018. Data was obtained using the cancer registry, supplemented with chart review. Patients were divided based on treatment completion and compared with respect to comorbidities, age, Eastern Cooperative Oncology Group (ECOG) score, and insurance status using univariate and multivariate analyses. RESULTS: 228 patients were identified: 53 Stage II and 175 Stage III. Of these, 24.5% of Stage II and 30.3% of Stage III patients did not complete chemotherapy. Neither ECOG status nor any comorbidity predicted failure to complete treatment. Those failing to complete chemotherapy were older (64.4 vs 60.8 years, P = .043). Additionally, those with public assistance or self-pay were less likely to complete chemotherapy than those with private insurance (P = .049). Both factors (older age/insurance status) remained significant on multivariate analysis (increasing age at diagnosis: OR 1.03, P =.034; public insurance: OR 1.84, P = .07; and self-pay status: OR 4.49, P = .03). CONCLUSIONS: No comorbidity was associated with failure to complete therapy, nor was frailty, as assessed by ECOG score. Though frailty was not significant, increasing age was, possibly reflecting negative attitudes toward chemotherapy in older populations. Insurance status also predicted failure to complete treatment, suggesting disparities in access to treatment, affected by socioeconomic factors.

Impact of Treatment Modalities on Discharge Disposition in Blunt Splenic Injuries.

BACKGROUND: Management of blunt splenic trauma has evolved over several decades, trending towards nonoperative management and splenic artery embolization. Extensive research has been conducted regarding the management of blunt splenic injuries, but there is little data on the association of treatment modality with discharge disposition. METHODS: This is an observational retrospective study conducted at a level-one trauma center with blunt splenic trauma patients of age ≥18 years between January 2010 and December 2021. The primary outcome of unfavorable discharge was defined as discharge to an acute care facility, intermediate care facility, long-term care facility, rehabilitation (inpatient) facility, or skilled nursing facility. RESULTS: Five hundred seventy-nine patients were included in the analysis, with 108 (18.7%) in the unfavorable group and 471 (81.3%) in the favorable group. Most patients were managed nonoperatively (69.3%), followed by splenectomy (25.0%) and embolization (5.7%). Due to the low number of embolizations performed during the study period, treatment modalities were grouped into two broad categories: intervention (embolization and splenectomies) and nonintervention. The treatment modality was found to have no significant impact on unfavorable discharge. Independent risk factors for unfavorable discharge included age >55 years, injury severity score (ISS) >15, hospital-acquired pneumonia, and in-hospital complications of sepsis. CONCLUSIONS: This study provides an understanding of specific demographic and clinical factors that may predispose blunt splenic injury trauma patients to an unfavorable discharge. Providers may apply these data to identify at-risk patients and subsequently adapt the care they provide in an effort to prevent the development of in-hospital pneumonia and sepsis.

Optimum utilization of cholecystokinin cholescintigraphy (CCK-HIDA) in clinical practice: an evidence based review.

Laparoscopic cholecystectomy remains one of the most commonly performed operations in the United States. Of the cholecystectomies performed, approximately 30% are carried out for a diagnosis of gallbladder dyskinesia, for which diagnosis is based on a reduced gallbladder ejection fraction as determined by a sincalide (cholecystokinin) stimulated hepatobiliary iminodiacetic scan (CCK-HIDA). Despite the widespread acceptance of this practice standardization of the test methodology and high quality data indicating efficacy of cholecystectomy in the treatment of this condition are lacking. This manuscript reviews this problem in detail based on the current available literature.