Optimizing Transitions of Care and Enhancing Surgical Education on Acute Care Surgery: A Multi-Institutional Survey Study.

OBJECTIVE: Critically ill and injured patients are routinely managed on the Trauma and Acute Care Surgery (ACS) service and receive care from numerous residents during hospital admission. The Clinical Learning Environment Review (CLER) program established by the ACGME identified variability in resident transitions of care (TC) while observing quality care and patient safety concerns. The aim of our multi-institutional study was to review surgical trainees' impressions of a specialty-specific handoff format in order to optimize patient care and enhance surgical education on the ACS service. DESIGN: A survey study was conducted with a voluntary electronic 20-item questionnaire that utilized a 5 point Likert scale regarding TC among resident peers, supervised handoffs by trauma attendings, and surgical education. It also allowed for open-ended responses regarding perceived advantages and disadvantages of handoffs. SETTING: Ten American College of Surgeons-verified Level 1 adult trauma centers. PARTICIPANTS: All general surgery residents and trauma/acute/surgical critical care fellows were surveyed. RESULTS: The study task was completed by 147 postgraduate trainees (125 residents, 14 ACS fellows, and 8 surgical critical care fellows) with a response rate of 61%. Institutional responses included: university hospital (67%), community hospital-university affiliate (16%), and private hospital-university affiliate (17%). A majority of respondents were satisfied with morning TC (62.6%) while approximately half were satisfied with evening TC (52.4%). Respondees believe supervised handoffs improved TC and prevented patient care delays (80.9% and 74.8%, respectively). A total of 35% of trainees utilized the open-ended response field to highlight specific best practices of their home institutions. CONCLUSIONS: Surgical trainees view ACS morning handoff as an effective standard to provide the highest level of clinical care and an opportunity to enhance surgical knowledge. As TC continue to be a focus of certifying bodies, identifying best practices and opportunities for improvement are critical to optimizing quality patient care and surgical education.

Nationwide Outcomes of Pancreaticoduodenectomy for Pancreatic Malignancies: Center Volume Matters.

BACKGROUND: Complex surgeries such as pancreaticoduodenectomies (PD) have been shown to have better outcomes when performed at high-volume centers (HVCs) compared to low-volume centers (LVCs). Few studies have compared these factors on a national level. The purpose of this study was to analyze nationwide outcomes for patients undergoing PD across hospital centers with different surgical volumes. METHODS: The Nationwide Readmissions Database (2010-2014) was queried for all patients who underwent open PD for pancreatic carcinoma. High-volume centers were defined as hospitals where 20 or more PDs were performed per year. Sociodemographic factors, readmission rates, and perioperative outcomes were compared before and after propensity score-matched analysis (PSMA) for 76 covariates including demographics, hospital factors, comorbidities, and additional diagnoses. Results were weighted for national estimates. RESULTS: A total of 19,810 patients were identified with age 66 ± 11 years. There were 6,840 (35%) cases performed at LVCs, and 12,970 (65%) at HVCs. Patient comorbidities were greater in the LVC cohort, and more PDs were performed at teaching hospitals in the HVC cohort. These discrepancies were controlled for with PSMA. Length of stay (LOS), mortality, invasive procedures, and perioperative complications were greater in LVCs when compared to HVCs before and after PSMA. Additionally, readmission rates at one year (38% vs 34%, P < .001) and readmission complications were greater in the LVC cohort. CONCLUSIONS: Pancreaticoduodenectomy is more commonly performed at HVCs, which is associated with less complications and improved outcomes compared to LVCs.

Cobimetinib Plus Gemcitabine: An Active Combination in KRAS G12R-Mutated Pancreatic Ductal Adenocarcinoma Patients in Previously Treated and Failed Multiple Chemotherapies.

Purpose: The KRAS proto-oncogene is involved in the RAS/MAPK pathway. KRAS is present in the wild type or mutated forms. The oncogene KRAS is frequently mutated in various cancers. At the time that amino acid glycine is mutated, KRAS protein acquires oncogenic properties that result in the tumor cell growth, proliferation, and cancer progression. There has been limited understanding of the different mutations at codon 12. The consequences of such mutations is not fully understood. Various G12X mutations in pancreatic cancer patients have been examined, with the most common mutations being G12D (40%), G12V (30%), and G12R (15-20%). Now we are understanding that G12X mutations in the KRAS are not all equal. Methods: In a single-arm exploratory study, we accrued 13 KRAS-G12X-mutated pancreatic patients (KRAS G12D, G12V, and G12R). They were divided into two groups: group 1 consisted of seven patients with G12D and G12V and group 2 included six patients with the KRAS G12R mutation. All patients were treated with the combination of gemcitabine at 1250 mg/m2 intravenous weekly for 3 weeks and oral cobimetinib 20 mg b.i.d. for 3 weeks. This was followed by a week of rest before the initiation of the next cycle. Results: In the first cohort, seven patients were on treatment, all of whom progressed and died within the 2 months of the study. In the second cohort, one of six patients achieved partial response, and five achieved stable disease. Median progression-free survival was 6 months (9% confidence interval 3.0-9.3 months) and overall survival has been reached at 8 months. Common adverse reactions included rash, fatigue, nausea, and vomiting (grades 2 and 3). Cancer antigen CA19-9 decreased by >50% in all group 2 patients. Conclusion: Our pancreatic cancer patients were heavily pretreated (all had received FOLFIRINOX and gemcitabine/nab-paclitaxel) before the entry into our trial. Upon entry into our trial, all patients were treated with the combination of gemcitabine and oral cobimetinib. Therefore, this constituted the second exposure of the patients to gemcitabine. This study illustrates a new discovery, which can potentially target 15-20% of pancreatic cancer patients and allow for a significant improvement in their prognosis. We will be conducting randomized phase II trials to substantiate our findings.

Publication Inaccuracies Listed in General Surgery Residency Training Program Applications.

BACKGROUND: Professionalism is a core competency that is difficult to assess. We examined the incidence of publication inaccuracies in Electronic Residency Application Service applications to our training program as potential indicators of unprofessional behavior. STUDY DESIGN: We reviewed all 2019-2020 National Resident Matching Program applicants being considered for interview. Applicant demographic characteristics recorded included standardized examination scores, gender, medical school, and medical school ranking (2019 US News & World Report). Publication verification by a medical librarian was performed for peer-reviewed journal articles/abstracts, peer-reviewed book chapters, and peer-reviewed online publications. Inaccuracies were classified as "nonserious" (eg incorrect author order without author rank promotion) or "serious" (eg miscategorization, non-peer-reviewed journal, incorrect author order with author rank promotion, nonauthorship of cited existing publication, and unverifiable publication). Multivariate logistic regression analysis was performed for demographic characteristics to identify predictors of overall inaccuracy and serious inaccuracy. RESULTS: Of 319 applicants, 48 (15%) had a total of 98 inaccuracies; after removing nonserious inaccuracies, 37 (12%) with serious inaccuracies remained. Seven publications were reported in predatory open access journals. In the regression model, none of the variables (US vs non-US medical school, gender, or medical school ranking) were significantly associated with overall inaccuracy or serious inaccuracy. CONCLUSIONS: One in 8 applicants (12%) interviewing at a general surgery residency program were found to have a serious inaccuracy in publication reporting on their Electronic Residency Application Service application. These inaccuracies might represent inattention to detail or professionalism transgressions.

Does a Laparoscopic Approach to Distal Pancreatectomy for Cancer Contribute to Optimal Adjuvant Chemotherapy Utilization?

BACKGROUND: Although laparoscopic distal pancreatectomy (LDP) versus open approaches (ODP) for pancreatic adenocarcinoma (PDAC) is associated with reduced morbidity, its impact on optimal adjuvant chemotherapy (AC) utilization remains unclear. Furthermore, it is uncertain whether oncologic resection quality markers are equivalent between approaches. METHODS: The National Cancer Database (NCDB) was queried between 2010 and 2016 for PDAC patients undergoing DP. Effect of LDP vs ODP and institutional case volumes on margin status, hospital stay, 30-day and 90-day mortality, administration of and delay to AC, and 30-day unplanned readmission were analyzed using binary and linear logistic regression. Cox multivariable regression was used to correct for confounders. RESULTS: The search yielded 3411 patients; 996 (29.2%) had LDP and 2415 (70.8%) had ODP. ODP had higher odds of readmission [odds ratio (OR) 1.681, p = 0.01] and longer hospital stay [ß 1.745, p = 0.004]. No difference was found for 30-day mortality [OR 1.689, p = 0.303], 90-day mortality [OR 1.936, p = 0.207], and overall survival [HR 1.231, p = 0.057]. The highest-volume centers had improved odds of AC [OR 1.275, p = 0.027] regardless of approach. LDP conferred lower margin positivity [OR 0.581, p = 0.005], increased AC use [3rd quartile: OR 1.844, p = 0.026; 4th quartile; OR 2.144, p = 0.045], and fewer AC delays [4th quartile: OR 0.786, p = 0.045] in higher-volume centers. CONCLUSIONS: In selected patients, LDP offers an oncologically safe alternative to ODP for PDAC independent of institutional volume. However, additional oncologic benefit due to optimal AC utilization and lower positive margin rates in higher volume centers suggests that LDP by experienced teams can achieve best possible cancer outcomes.

Case distributions in general surgery residency: Subspecialization occurs before fellowship.

BACKGROUND: In the era of subspecialization and duty-hour restrictions, many General Surgery residents desire additional training in their future subspecialty areas. This study examines the relationship between case distributions performed by General Surgery residents and their chosen future subspecialty. METHODS: A retrospective review of Accreditation Council for Graduate Medical Education case logs of 101 graduated General Surgery residents at a single academic institution (2002-2018) was performed. The total number of operative cases performed during General Surgery residency overall and in Accreditation Council for Graduate Medical Education-defined categories were compared between residents with differing areas of future subspecialization. RESULTS: Residents pursuing surgical fellowships in Endocrine, Cardiothoracic, Vascular, and Trauma/Critical Care Surgery logged respectively more endocrine (63 [11] vs 32 [13]; P < .001), thoracic (61 [15] vs 41 [13]; P < .001), vascular (225 [38] vs 162 [38]; P < .001), and operative trauma (83 [29] vs 71 [25]; P = .045) cases, compared with program average. Residents pursuing General Surgery (no fellowship) performed significantly more endoscopies (131 [47] vs 105 [28]; P = .029) than peers. Residents pursuing Breast, Oncology, Colorectal, and Pediatric Surgery fellowships performed numerically (non-significantly) more breast (94 [16] vs 78 [20]; P = .180), liver/pancreas (39 [3.1] vs 33 [8.0]; P = .173), large intestinal (132 [30] vs 125 [24]; P = .507), and pediatric (173 [27] vs 155 [37]; P = .832) cases, respectively, compared with peers. The majority of these additional cases were performed in postgraduate years 3 to 5. CONCLUSION: In this single-institution study, many General Surgery residents perform more cases than peers in respective areas of future subspecialization. This may reflect residents at the reporting institution, and similar large, university-based programs seeking focused training in preparation for fellowship while still meeting case-volume minimums in all Accreditation Council for Graduate Medical Education-defined categories.

Utilization of a Modified Roux-en-Y Anastomosis as an Access point for Percutaneous Transjejunal Cholangioplasty of Recurrent Biliary Strictures.

INTRODUCTION: Biliary duct injuries pose a significant management challenge due to the propensity for recurrent biliary strictures. Development of a modified Roux-en-Y hepaticojejunostomy known as a Hutson-Russell Pouch (HRP) provides a point of entry for repetitive access to the biliary tree. We aim to highlight the effectiveness of using the HRP as an access point for the long-term management of anastomotic and distal biliary strictures, thereby showcasing the value in potential widespread adoption of this modification to a standard surgical procedure. MATERIALS AND METHODS: IRB-approved retrospective study of 36 patients (10 M, 26 F; mean age 55.19 ± 13.94; 15-83) underwent a total of 110 transjejunal cholangiograms. Indications for cholangiogram included cholangitis (n = 38), surveillance (n = 36), and elevated liver enzymes (n = 36). Technical success was defined by the ability to access and intervene in the biliary tree via HRP access. In case of stenosis, the ability to successfully dilate (< 30%) residual stenosis was considered a technically successful procedure. Clinical success was defined by normalization of the liver function tests or resolution of cholangitis. RESULTS: Technical success was achieved in 83/110 (75.45%) of the cases, and clinical success was achieved in 102/110 (98.2%). Transhepatic access was needed in 27/110 (24.5%) of the cases. Interventions performed included balloon cholangioplasty in 104/110 (94.5%), biliary stone removal in 2/110 (1.8%), biliary stent placement in 2/110 (1.8%), and biliary drain placement in 4/110 (3.6%). There were a total of 9/110 complications (8.2%). CONCLUSION: The HRP was an effective access point in the management of recurrent benign biliary strictures in this cohort.

Minimal-invasive approach to pancreatoduodenectomy is associated with lower early postoperative morbidity.

OBJECTIVES: We aim to investigate the impact of the operation time for pancreatoduodenectomy (PD) in different surgical approaches. METHODS: The NSQIP database was used to examine the clinical data of patients underwent PD during 2014-2016. RESULTS: We sampled a total of 6151 patients who underwent elective PD. Of these, 452(7.3%) had minimally invasive approaches to PD. Minimally invasive approaches (MIS) to PD was associated with a significant decrease in morbidity of patients (AOR: 0.67, P < 0.01). Following risk adjustment for morbidity predictors, operation length was statistically associated with post-operative morbidity (AOR: 1.002, P < 0.01). Although MIS procedures were significantly longer operations compared to open procedures (443 min vs. 371 min, CI: 53-82 min, P < 0.01), MIS approaches were associated with significantly decreased morbidity in low stage tumors (stage zero-II) (51.3% vs. 56.2%, AOR: 0.72, P = 0.03) and advanced stage disease (stage III-IV) (50% vs. 60.3%, AOR: 0.38, P = 0.04). CONCLUSION: Minimally invasive approaches to PD were associated with decreased post-operative morbidity, even though they were associated with longer operative times. Operation length also significantly correlated with postoperative morbidity.

Hepatocellular carcinoma: resection with adjuvant hepatic artery infusion therapy vs resection alone. A systematic review and meta-analysis.

Hepatocellular carcinoma (HCC) has a recurrence rate of up to 70% in 5 years after resection, detrimentally lowering survival. The role of adjuvant therapy remains controversial; therefore, the aim of this study was to evaluate the disease-free and overall survival of patients with HCC, not candidates for transplantation, undergoing resection and adjuvant hepatic artery infusion therapy vs resection alone. Our meta-analysis showed that adjuvant HAIC improves overall and disease-free survival after resection, especially in tumors ≥7 cm.

The Role of Surgical Resection for Stage IV Gastric Cancer With Synchronous Hepatic Metastasis.

BACKGROUND: With improved responses to chemotherapy and targeted treatments, the role of surgery in metastatic gastric cancer (MGC) to the liver needs to be revisited. We sought to examine whether surgical resection is associated with improvement of long-term survival. METHODS: The National Cancer Database was queried for MGC to the liver (2010-2014). Survival analysis was performed to compare the effect of gastrectomy and perioperative chemotherapy (G-CT) to palliative chemotherapy (PCT) alone. RESULTS: We identified 3175 patients with MGC to the liver. Most patients (94%, n = 2979) were treated with PCT, whereas 6% (n = 196 patients) underwent G-CT. Overall survival improved in patients treated with G-CT compared to PCT alone (16 versus 9.7 mo, P < 0.001). In patients undergoing G-CT, neoadjuvant chemotherapy was associated with increased overall survival compared to adjuvant chemotherapy (18.9 versus 14.8 mo, P = 0.011). Hazards of death significantly decreased with gastrectomy (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.44-0.63, P < 0.001). Negative prognostic factors included advanced age (HR: 1.10, 95% CI: 1.06-1.14, P < 0.001), treatment at nonacademic institution (HR: 1.23, 95% CI: 1.13-1.33, P < 0.001), and poorly differentiated grade (HR: 1.54, 95% CI: 1.17-2.03, P < 0.001). CONCLUSIONS: G-CT is associated with improved survival in patients with gastric cancer and synchronous liver metastasis. Further experience with well-designed prospective trials may be warranted to confirm these findings.

Better ABSITE performance with increased operative case load during surgical residency.

BACKGROUND: Common measures of evaluating surgical resident progression include American Board of Surgery In-Training Exam scores and Accreditation Council for Graduate Medical Education operative case logs. This study evaluates the relationship between operative cases performed and American Board of Surgery In-Training Exam scores in general surgery residents. METHODS: A retrospective review of American Board of Surgery In-Training Exam scores and operative case logs was performed for postgraduate year 1-5 general surgery residents at a single academic institution (2008-2017). For each resident, the total number of operative cases logged from the start of their postgraduate year 1 until the end of each academic year was calculated and compared to their American Board of Surgery In-Training Exam scores for that corresponding year. RESULTS: At all postgraduate-year levels, there was a positive linear relationship between the number of cases logged and American Board of Surgery In-Training Exam percentile (slope, m = 0.23-5.2, R2 .01-.17) and scaled (m = 0.29-5.3, R2 .13-.37) scores. At the postgraduate year 1, 2, 3, and 5 levels, and with all residents combined, residents in the top quartile of cases logged performed significantly better on the American Board of Surgery In-Training Exam than those in the bottom quartile (P < .05). CONCLUSION: Surgical residents who perform more operative cases do significantly better on the American Board of Surgery In-Training Exam than their peers. This association may be due to increased clinical experience, exposure to pathology, and/or individual resident motivation.

Total retroperitoneal approach to aortic reconstruction: A novel technique for aorto-enteric fistulae and graft infections.

Aorto-enteric fistulae pose a challenging negative outcome of aortic intervention. Treatment involves graft excision, and recently, more enthusiasm has met in situ revascularization over extra-anatomic bypass. This has been traditionally performed through the transperitoneal approach via a midline abdominal incision. We propose an exclusively total retroperitoneal technique in managing this complication with regard to both the vascular and alimentary tract technical aspects of the procedure. This involves exclusion and bypass of the affected segment followed by en-mass resection of the affected segment with the duodenum, and finally, bowel anastomosis. We present a case of an aorto-enteric fistulae illustrating classical radiological findings treated via a flank incision and retroperitoneal technique after a temporizing endovascular stent placement at an outside institution. Peri-operative course was uneventful. The retroperitoneal approach has been shown to be equivalent to its transperitoneal counterpart in many aspects of treating aortic disease. It has also been shown to be superior in others, including but not limited to, faster return of bowel function, decreased respiratory complications, less blood loss and shorter length of stay in the intensive care unit (ICU) and hospital. We recommend adding this approach to every vascular surgeons operative armamentarium when it comes to managing aorto-enteric fistulae. This might be especially helpful in avoiding re-operative planes, thus minimizing blood loss and iatrogenic bowel injury, better aortic exposure, and adequate access to the duodenum.

Pancreatic Neuroendocrine Tumors (panNETs): Analysis of Overall Survival of Nonsurgical Management Versus Surgical Resection.

BACKGROUND: Outcomes of patients with pancreatic neuroendocrine tumors (panNETs) undergoing surgical or nonsurgical management and outcomes of enucleation versus standard resection were compared. METHODS: MEDLINE, EMBASE, PubMed, Scopus, and Cochrane were queried (2000 to present). All studies comparing patients undergoing surgical versus nonsurgical treatments, or enucleation versus standard resection, were included. Pooled risk ratios and 95% CI for survival were calculated. RESULTS: Eleven studies met criteria with 1491 resected and 1607 nonsurgically managed patients. Meta-analysis showed improved overall survival with resection at 1 year (risk ratio (RR) = 1.281, CI 1.064-1.542, p = 0.009), 3 years (RR = 1.837, CI 1.594-2.117, p < 0.001), and 5 years (RR = 2.103, CI 1.50-2.945, p < 0.001). OS of patients with resected nonfunctioning panNETs was improved at 3 years (RR = 1.847, CI 1.477-2.309, p < 0.001) and 5 years (RR = 1.767, CI 1.068-2.924, p = 0.027). OS was improved when panNETs ≤2 cm were resected at 3 years (RR = 1.695, CI 1.269-2.264, p < 0.001) and 5 years (RR = 2.210, CI 1.749-2.791, p < 0.001). Fifteen articles met criteria for enucleation versus standard resection (n = 1035; 620 were nonfunctioning). Enucleation had shorter operative time (weighted mean difference (WMD) = -95.6 min, 95% CI -131.4 to -59.8, p < 0.01), less operative blood loss (WMD = -172.6 ml, 95% CI -340 to -5.1, p = 0.04), but increased postoperative pancreatic fistula (POPF) (RR = 2.08, 95% CI 1.39-3.12, p < 0.01). CONCLUSION: Surgical resection of panNETs, including small and nonfunctioning, appears to be associated with improved OS. Enucleation is associated with shorter operative time, less blood loss, but greater incidence of POPF. Prospective, randomized clinical trials are needed to confirm these results.

Distal pancreatectomy for benign and low grade malignant tumors: Short-term postoperative outcomes of spleen preservation-A systematic review and update meta-analysis.

BACKGROUND: The value of spleen preservation with distal pancreatectomy (DP) for benign and low grade malignant tumors remains unclear. The aim of this study was to evaluate the short-term postoperative clinical outcomes in patients undergoing DP with splenectomy (DPS) or spleen preservation (SPDP). METHODS: Online database search was performed (2000 to present); key bibliographies were reviewed. Studies comparing patients undergoing DP with either DPS or SPDP, and assessing postoperative complications were included. RESULTS: Meta-analysis of included data showed SPDP patients had significantly less operative blood loss, shorter duration of hospitalization, lower incidence of fluid collection and abscess, lower incidence of postoperative splenic and portal vein thrombosis, and lower incidence of new onset postoperative diabetes. For the whole group, there was no difference in incidence of postoperative pancreatic fistula (POPF) (RR = 0.95; 95%CI 0.65-1.40, P = 0.80), however, subgroup analysis of studies using ISGPF criteria showed that DPS patients had increased rates of Grade B/C POPF (RR = 1.35; 95%CI 1.08-1.70, P = 0.01). CONCLUSIONS: SPDP for benign and low grade malignant tumors is associated with shorter hospital stay and decreased morbidity compared to DPS. J. Surg. Oncol. 2017;115:137-143. © 2017 Wiley Periodicals, Inc.

Global Gene Expression Change Induced by Major Thoracoabdominal Surgery.

OBJECTIVE: To test the hypothesis that major thoracoabdominal surgery induces gene expression changes associated with adverse outcomes. BACKGROUND: Widely different traumatic injuries evoke surprisingly similar gene expression profiles, but there is limited information on whether the iatrogenic injury caused by major surgery is associated with similar patterns. METHODS: With informed consent, blood samples were obtained from 50 patients before and after open transhiatal esophagectomy or pancreaticoduodenectomy. Twelve cases with complicated recoveries (death, infection, venous thromboembolism) were matched with 12 cases with uneventful recoveries. Global gene expression was assayed using human microarray chips. A 2-fold change with a corrected P < 0.05 was considered differentially expressed. RESULTS: In these 24 patients, 522 genes were differentially expressed after surgery; 248 (48%) were upregulated (innate immunity and inflammation) and 274 (52%) were downregulated [adaptive immunity (antigen presentation, T-cell function)]. Hierarchical clustering of the profile reliably predicted pre- and postoperative status. The within-patient change was 3.08 ±â€Š0.91-fold. There was no measurable association with age, malignancy, procedure, surgery length, operative blood loss, or transfusion requirements, but was positively associated with postoperative infection (3.81 ±â€Š0.97 vs 2.79 ±â€Š0.73; P = 0.009) and hospital length of stay (r = 0.583, P = 0.003). Venous thromboembolism and mortality each occurred in one patient, thus no associations were possible. CONCLUSIONS: Major surgery induces a quantifiable pattern of gene expression change that is associated with adverse outcome. This could reflect early impaired adaptive immunity and suggests potential therapeutic targets to improve postoperative recovery.

Vascular Reconstruction Is Not Warranted in Most Civilian Traumatic Shank Vascular Injuries.

BACKGROUND: Operative management of traumatic shank vascular injuries (SVI) evolved significantly in the past few decades, thereby leading to a dramatic decrease in amputation rates. However, there is still controversy regarding the minimum number of patent shank arteries sufficient for limb salvage. METHODS: Between January 2006 and September 2011, 191 adult trauma patients presented to an urban level I trauma center in Miami, Florida, with traumatic lower extremity vascular injuries. Variables collected included age, gender, mechanism of injury, and clinical status at presentation. Surgical data included vessel injury, technical aspects of repair, associated complications, and outcomes. RESULTS: A total of 48 (25.1%) patients were identified comprising 66 traumatic shank arterial injuries. Mean age was 38.2 ± 13.4 years, and the majority of patients were men (40 patients, 83.3%) presenting with blunt injuries (35 patients, 72.9%). Ligation was performed in 38 injured arteries (57.6%) and no vascular intervention was required in 20% of the patients. Vascular reconstruction was performed in only 6 patients (9.1%): 4 (6.1%) with concurrent popliteal trauma, 1 (1.5%) isolated anterior tibial, and 1 (1.5%) 3-vessel injury. Autogenous venous interposition conduit and polytetrafluoroethylene grafting were performed in 5 (7.6%) and 1 (1.5%) patient, respectively. All amputations (8 patients, 16.7%) occurred in blunt trauma patients presenting with unsalvageable limbs. The overall mortality rate in this series was 2.1%. CONCLUSIONS: Civilian shank arterial injuries are associated with acceptable rates of limb loss. Patients with a single-vessel patent inflow did not require vascular reconstruction in this series. Arterial reconstruction may no longer be determinant for successful management of isolated and double arterial SVI, whereas it is yet essential in the presence of 3-vessel or concurrent above-the-knee vascular injuries. Further investigation including larger number of patients is still warranted to define the role of conservative management in these complex injuries.

Delayed gastric emptying after pancreaticoduodenectomy.

BACKGROUND: Delayed gastric emptying (DGE) remains an unsolved complication after pancreaticoduodenectomy (PD) with conflicting reports of its cause. We aimed to compare the effect of surgical techniques involving the stomach in PD in lowering the risk of postoperative DGE. METHODS: Online search and review of key bibliographies in PubMed, Medline, Embase, Scopus, Cochrane, and Google Scholar was performed. Studies comparing PD surgical techniques were identified. Primary outcome was postoperative DGE. Methodological quality was assessed using Strengthening the Reporting of Observational Studies in Epidemiology and Consolidated Standards of Reporting Trials. Calculated pooled relative risk and odds ratios (ORs) with the corresponding 95% confidence interval (CI) were used in the meta-analyses. RESULTS: Overall, 376 studies were reviewed, of which 22 studies were selected including a total of 5172 patients. The incidence of DGE was lower in antecolic compared with retrocolic gastrojejunostomy (risk ratio [RR], 0.260; CI, 0.157-0.431; P < 0.001; n = 1067 patients) and in subtotal stomach preserving PD compared with pylorus preserving PD (RR, 0.527; CI, 0.363-0.763; P < 0.001; n = 663 patients). There was no significant difference between classic PD versus pylorus preserving PD (OR, 0.64; CI, 0.40-1.00; P = 0.05; n = 1209 patients), pancreaticogastrostomy versus pancreaticojejunostomy (RR, 1.02; CI, 0.62-1.68; P = 0.94; n = 961 patients), Roux-en-Y versus Billroth II gastrojejunostomy (RR, 0.946; CI, 0.788-1.136; P = 0.5513; n = 470 patients), or minimally invasive PD versus open PD (OR, 0.99; CI, 0.62-1.56; P = 0.96; n = 802). CONCLUSIONS: In PD, surgical techniques using antecolic reconstruction route and subtotal stomach preserving PD seem to be associated with a lower risk of DGE. Further randomized controlled trials are necessary to evaluate these results taking other causes into consideration.

Delayed gastric emptying after pylorus preserving pancreaticoduodenectomy--does gastrointestinal reconstruction technique matter?

BACKGROUND: The best gastrointestinal reconstruction route after pylorus preserving pancreaticoduodenectomy remains debatable. We aimed to evaluate the incidence of delayed gastric emptying (DGE) after antecolic (AC) and retrocolic (RC) duodenojejunostomy in these patients. DATA SOURCES: Studies comparing AC to RC reconstruction after pylorus preserving pancreaticoduodenectomy were identified from literature databases (PubMed, MEDLINE, EMBASE, SCOPUS, and Cochrane). The meta-analysis included 10 studies with a total of 1,067 patients, where 504 patients underwent AC and 563 patients underwent RC reconstruction. The incidence of DGE was significantly lower with AC reconstruction in both randomized controlled trials (risk ratio = .44, confidence interval = .24 to.77, P = .005) and retrospective studies (risk ratio .21, confidence interval .14 to .30, P < .001) with less output and days of nasogastric tube use. AC reconstruction was associated with a decreased length of stay. There was no difference in operative time, blood loss, pancreatic fistula, and abdominal abscess/collections. CONCLUSIONS: AC reconstruction seems to be associated with less DGE, with no association with pancreatic fistula or abscess formation.

Association Between American Board of Surgery In-Training Examination Scores and Resident Performance.

IMPORTANCE: The American Board of Surgery In-Training Examination (ABSITE) is designed to measure progress, applied medical knowledge, and clinical management; results may determine promotion and fellowship candidacy for general surgery residents. Evaluations are mandated by the Accreditation Council for Graduate Medical Education but are administered at the discretion of individual institutions and are not standardized. It is unclear whether the ABSITE and evaluations form a reasonable assessment of resident performance. OBJECTIVE: To determine whether favorable evaluations are associated with ABSITE performance. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional analysis of preliminary and categorical residents in postgraduate years (PGYs) 1 through 5 training in a single university-based general surgery program from July 1, 2011, through June 30, 2014, who took the ABSITE. EXPOSURES: Evaluation overall performance and subset evaluation performance in the following categories: patient care, technical skills, problem-based learning, interpersonal and communication skills, professionalism, systems-based practice, and medical knowledge. MAIN OUTCOMES AND MEASURES: Passing the ABSITE (≥30th percentile) and ranking in the top 30% of scores at our institution. RESULTS: The study population comprised residents in PGY 1 (n = 44), PGY 2 (n = 31), PGY 3 (n = 26), PGY 4 (n = 25), and PGY 5 (n = 24) during the 4-year study period (N = 150). Evaluations had less variation than the ABSITE percentile (SD = 5.06 vs 28.82, respectively). Neither annual nor subset evaluation scores were significantly associated with passing the ABSITE (n = 102; for annual evaluation, odds ratio = 0.949; 95% CI, 0.884-1.019; P = .15) or receiving a top 30% score (n = 45; for annual evaluation, odds ratio = 1.036; 95% CI, 0.964-1.113; P = .33). There was no difference in mean evaluation score between those who passed vs failed the ABSITE (mean [SD] evaluation score, 91.77 [5.10] vs 93.04 [4.80], respectively; P = .14) or between those who received a top 30% score vs those who did not (mean [SD] evaluation score, 92.78 [4.83] vs 91.92 [5.11], respectively; P = .33). There was no correlation between annual evaluation score and ABSITE percentile (r(2) = 0.014; P = .15), percentage correct unadjusted for PGY level (r(2) = 0.019; P = .09), or percentage correct adjusted for PGY level (r(2) = 0.429; P = .91). CONCLUSIONS AND RELEVANCE: Favorable evaluations do not correlate with ABSITE scores, nor do they predict passing. Evaluations do not show much discriminatory ability. It is unclear whether individual resident evaluations and ABSITE scores fully assess competency in residents or allow comparisons to be made across programs. Creation of a uniform evaluation system that encompasses the necessary subjective feedback from faculty with the objective measure of the ABSITE is warranted.