Residency training oversight(s) in surgery: the history and legacy of the accreditation council for graduate medical education reforms.

Despite a quarter century of discourse since a sentinel event in New York City raised the question of appropriate oversight for graduate medical education, many questions remain unanswered. Even with the Accreditation Council for Graduate Medical Education rules in place, some opportunity remains to examine handoff methodology, the relationship of duty hours to education, and the impact of fatigue on resident performance. Neurophysiologic adjuncts applied concomitantly to evaluation of didactic performance offer promise for data-driven definition of the optimal shift. Concurrently, the merits of specialty-specific oversight of graduate medical education remain under active consideration.

Transverse mesocolonic hernia of the jejunum mimicking pancreatic neoplasm.

A patient admitted repetitively for vomiting was found to have a radiologic abnormality in the lesser sac, initially interpreted as a pancreatic mass. At exploration, intestinal obstruction due to transmesocolonic herniation of the jejunum explained both the symptoms and the radiologic finding.

Choledochojejunostomy revision performed by using the laparoscopic linear cutter.

Choledochojejunostomy is commonly performed for biliary bypass for benign and malignant disease. Anastomotic stricture is a known complication of enteric surgery. We report the use of the laparoscopic linear cutter at laparotomy to revise a choledochojejunostomy created 12 years previously for benign disease.

Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy.

BACKGROUND: When small bowel obstruction is demonstrated clinically or radiographically to be complete, operation is advocated because of the demonstrated association of strangulation obstruction with complete obstruction and the difficulty of diagnosing strangulation obstruction. Short observation periods, fluoroscopic procedures, and cross-sectional imaging are used in treatment of partial obstruction by those who believe that observation is futile or dangerous. This approach holds that few patients resolve after a day or two of observation; if this premise were true, protracted observation should see few patients resolve and some require resection for necrotic bowel after failed observation. Observer bias and the spectrum of nonnecrotic ischemia makes end-point analysis after laparotomy difficult to interpret; few criteria or incentives exist for a surgeon to speculate that a patient brought to surgery might have recovered without it. STUDY DESIGN: I reviewed the clinical courses of 413 obstructed patients seen over 13 years. RESULTS: Seventy-two patients underwent immediate treatment for complete obstruction, 294 resolved without operation, and 47 patients required operation after a period of observation ranging from 3 to 15 days. All observed patients were followed using clinical examination, leukocyte count, and plain film radiography only. No bowel resections were required in patients who were observed. CONCLUSIONS: Research opportunities exist for use of alternatives to plain film imaging in treatment of partial small bowel obstruction, but this series does not support the premise that there is a risk for bowel ischemia or bowel resection by observing patients with partial small bowel obstruction or by following them with plain films alone. Indeed, such a strategy resulted in resolution in 294 of 341 patients so treated, with readmission and reoperation rates comparable with those reported in series in which earlier operation was undertaken.