Oncological outcome of peripartum colorectal carcinoma-a single-center experience.

OBJECTIVES: This study aimed to analyze disease presentation, management, and oncological outcomes of patients diagnosed with peripartum colorectal cancer (CRC). METHODS: Retrospective cohort study of all consecutive women of childbearing age (18-45 years) between 2002 and 2014 diagnosed with CRC adenocarcinoma at a tertiary academic institution. Patients who experienced pregnancy within 12 months of their diagnosis (peripartum period, group 1) were compared to the remaining patients of the cohort (group 2). Overall survival (OS) was compared between the two groups through Kaplan-Meier estimates. RESULTS: Out of 555 consecutive women with a mean age of 37.8 + 6 years, 31 (5.6%) were diagnosed with CRC in the peripartum period. Of these, all patients were symptomatic during pregnancy due to bleeding, abdominal pain, or constipation; however, only 11 CRC (35.5%) were diagnosed during pregnancy, 1 (3.2%) during C section, and the remaining (61.3%) postpartum. TNM stage at presentation was I in 6 patients (19.4%), II in 4 patients (13.9%), III in 8 patients (25.8%), and IV in 13 patients (41.9%). Surgical resection was performed in 23 patients (74.2%): 2 while pregnant, 2 at the time of C section, and the remainder postpartum. Across all stages, OS was 95% at 1 year and 62% at 5 years and did not differ between the two comparative groups (p = 0.16). CONCLUSIONS: A suspicious attitude towards cancer-related symptoms during pregnancy is crucial to prevent delayed evaluation for CRC.

Validation of the American Association for the Surgery of Trauma's emergency general surgery breast infection grading system.

BACKGROUND: The American Association for the Surgery of Trauma (AAST) developed emergency general surgery (EGS) grading systems for multiple diseases to standardize classification of disease severity. The grading system for breast infections has not been validated. We aimed to validate the AAST breast infection grading system. METHODS: Multi-institutional retrospective review of all adult patients with a breast infection diagnosis at Mayo Clinic Rochester 1/2015-10/2015 and Pietermaritzburg South African Hospital 1/2010-4/2016 was performed. AAST EGS grades were assigned by two independent reviewers. Inter-rater reliability was measured using the agreement statistic (kappa). Final AAST grade was correlated with patient and treatment factors using Pearson's correlation coefficient. RESULTS: Two hundred twenty-five patients were identified: grade I (n = 152, 67.6%), II (n = 44, 19.6%), III (n = 25, 11.1%), IV (n = 0, 0.0%), and V (n = 4, 1.8%). At Mayo Clinic Rochester, AAST grades ranged from I-III. The kappa was 1.0, demonstrating 100% agreement between reviewers. Within the South African patients, grades included II, III, and V, with a kappa of 0.34, due to issues of the grading system application to this patient population. Treatment received correlated with AAST grade; less severe breast infections (grade I-II) received more oral antibiotics (correlation [-0.23, P = 0.0004]), however, higher AAST grades (III) received more intravenous antibiotics (correlation 0.29, P <0.0001). CONCLUSIONS: The AAST EGS breast infection grading system demonstrates reliability and ease for disease classification, and correlates with required treatment, in patients presenting with low-to-moderate severity infections at an academic medical center; however, it needs further refinement before being applicable to patients with more severe disease presenting for treatment in low-/middle-income countries.

Minimal cosmetic revision required after minimally invasive pectus repair.

BACKGROUND: Despite surgical correction procedures for pectus deformities, remaining cosmetic asymmetry may have significant psychological effects. We sought to evaluate factors associated with plastic surgery (PS) consultation and procedures for these deformities at an academic institution. METHODS: We reviewed patients aged 0-21 diagnosed with a pectus excavatum or carinatum deformity at our institution between January 2001 and October 2016. Pectus diagnoses were identified by ICD-9/ICD-10 codes and surgical repair by CPT codes; patients receiving PS consultation were identified by clinical note service codes. Student's t tests, Fisher's exact tests, and Chi-squared tests were utilized. RESULTS: 2158 patients were diagnosed with a pectus deformity; 442 (20.4%) underwent surgical correction. 19/442 (4.3%) sought PS consultation, either for pectus excavatum [14/19 (73.7%)], carinatum [4/19 (21.0%)], and both [1/19 (5.3%)], (p = 0.02). Patients seeking PS consultation were more likely to be female (p < 0.01), have scoliosis (p = 0.02), or undergo an open repair (p < 0.01). The need for PS consultation did not correlate with Haller index, p = 0.78. CONCLUSION: PS consultation associated with pectus deformity repair was rare, occurring in < 5% of patients undergoing repair. Patients who consulted PS more commonly included females, patients with scoliosis, and those undergoing open repair. These patients would likely benefit most from multidisciplinary pre-operative discussions regarding repair of the global deformity.

Risk factors for postoperative hematoma after inguinal hernia repair: an update.

BACKGROUND: We recently sensed an increase in the frequency of groin hematoma after inguinal hernia repair (IHR) at our institution. The aim of this study was to provide a more updated assessment of the risk factors inherent to this complication. METHODS: We performed a case-control study of all adult patients (age ≥ 18 y) who developed a groin hematoma after IHR at our institution between 2003 and 2015. Univariate and multivariable analyses were performed to assess for independent predictors for groin hematoma. RESULTS: A total of 96 patients (among 6608 IHR) developed a groin hematoma, (60 were observed, 36 required intervention). The hematoma frequency increased from our previous study (1.4 % versus 0.9%, P < 0.01). Mean age was 64.6 y (range: 18-92), and 84.3% were men. There was no significant difference in the laterality, type, or technique of IHR between cases and controls. Univariate analysis (odds ratio [95% confidence interval], P) identified warfarin usage (3.5, [1.6-6.4], P < 0.01), valvular heart disease (11.6, [2.6-51.3], P < 0.01), atrial fibrillation (2.6, [1.2-5.5], P = 0.01), hypertension (2.03, [1.1-3.6], P = 0.02), recurrent hernia (3.7, [1.4-9.7], P < 0.01), and coronary artery disease (2.1, [1.0-4.4 ], P = 0.05) as significant preoperative factors. The proportion of patients on warfarin decreased since our prior report (31% versus 42%, P = 0.20). On multivariable regression, warfarin and recurrent hernia were independent predictors of hematoma development. CONCLUSIONS: Independent risk factors for the development of groin hematoma after IHR included warfarin use and recurrent hernia. Careful consideration for anticoagulation and surgical hypervigilance remains prudent in all patients undergoing IHR and especially those with recurrence.

Survival following synchronous colon cancer resection.

BACKGROUND: Synchronous colon cancers, defined as two or more primary colon cancer detected simultaneously at the time of initial diagnosis, account for up to 5% of all colon cancer diagnoses. Management principles and outcomes remain largely undefined. METHODS: A retrospective institutional review of patients undergoing curative intent resection for colon adenocarcinoma (Stages I-III) from 1995 to 2007 was performed. Hereditary causes or inflammatory bowel disease were excluded. Matching was performed and Kaplan-Meier analysis was used to compare overall survival. RESULTS: Of 2,387 patients, 100 (4.2%) had synchronous cancers. Patients with synchronous lesions tended to be older (median 77 vs. 72 years, P < 0.001) with more advanced tumors (41.0% vs. 31.4% Stage III, P = 0.04). After matching, there were no differences in demographics or tumor factors (all P > 0.05). Compared to solitary, synchronous cancers demonstrated an inferior 10-year overall survival (53.9% vs. 36.5%, P = 0.009). Subset analysis of patients with synchronous cancers showed no difference in overall survival between those with extended versus segmental resections at 120-months (P = 0.07). CONCLUSION: Synchronous colon cancer is associated with decreased overall survival compared to patients with solitary tumors. Extended resection does not confer a survival benefit in these patients. Further research is needed to determine how to mitigate the poor outcomes. J. Surg. Oncol. 2016;114:80-85. © 2016 Wiley Periodicals, Inc.

Influencing Mindsets and Motivation in Procedural Skills Learning: Two Randomized Studies.

OBJECTIVES: An incremental (growth) theory of intelligence (mindset), compared with an entity (fixed) mindset, has been associated with improved motivation and performance. Interventions to induce incremental beliefs have improved performance on non-surgical motor tasks. We sought to evaluate the impact of 2 brief interventions to induce incremental beliefs in the context of learning a surgical task. DESIGN: Two randomized experiments. PARTICIPANTS AND SETTING: Secondary school students participating in medical simulation-based training activities at an academic medical center. INTERVENTIONS: We created 4 instructional messages intended to influence mindsets (two 60-second videos in Study 1, 2 fabricated "journal articles" in Study 2). In each study, one message emphasized that ability improves with practice (incremental); the other emphasized that ability is fixed (entity). After reviewing their randomly-assigned message, participants completed a laparoscopic cutting task as many times as they desired. Measurements included performance (product quality, self-reported task, and completion time), task persistence (repetitions), and entity beliefs. RESULTS: Two hundred and three students completed Study 1. Postevent entity beliefs (1 = lowest, 6 = highest) were similar between groups (incremental, 2.0vs entity, 2.0; p = 0.78). Contrary to hypothesis, the incremental video group demonstrated slower time (276vs 191 seconds; p < 0.0001), lower product quality (7.2vs 3.8mm deviation; p < 0.0001), and fewer task repetitions (1.4vs 1.8; p = 0.02). In Study 2, 113 participants provided outcomes related to mindset beliefs, but only 14 provided usable performance outcomes. Postevent entity beliefs were lower in the incremental article group (1.7vs 2.4; p < 0.0001). Task time (507vs 585 seconds; p = 0.40) and quality (7.1vs 7.5mm deviation; p = 0.85) were similar between groups. CONCLUSIONS: Brief motivational interventions can influence procedural performance and motivation. We need to better understand motivation and other affective influences on procedural skills learning. Mindset theory shows promise in this regard.

Personalized video feedback improves suturing skills of incoming general surgery trainees.

BACKGROUND: The American Board of Surgery encourages graduating medical students to prepare for surgical residency before day 1. We sought to determine the impact of personalized video feedback on an advance preparation task. METHODS: We conducted a nonrandomized study comparing video feedback versus no feedback. We sent incoming surgical interns a preparatory package 2 months before starting residency. Trainees video-recorded themselves performing a subcuticular wound closure, 3 times at 3-week intervals, and submitted these for appraisal. A staff surgeon provided personalized feedback on each video as a narrated voiceover. The voiced-over videos were then returned to trainees. We compared performance (time and completion rate) on suturing in a multistation assessment against residents from the previous year (no-feedback group). RESULTS: The feedback group had a higher completion rate for the suturing assessment than the no-feedback group (23/28 [82%] vs. 8/27 [30%], P < .0001). The feedback group also completed the suturing station at a faster rate than those without feedback (hazard ratio 4.9 [95% confidence interval (CI): 2.2,11.2), P < .0001). Global rating scores were significantly higher for the feedback group (mean difference [5-point scale] = 0.7 [95% CI: 0.3, 1.1]). However, Objective Structured Assessment of Technical Skills scores indicated no significant difference between groups (mean difference [5-point scale] = 0.3 [95% CI: 0.0, 0.6]). Within the feedback group, we found significant improvement from baseline to final performances (mean difference = 109 seconds [95% CI: 79, 140]). CONCLUSION: Personalized narrated feedback as part of a home-based advance preparation package for incoming residents is associated with higher performance on early objective assessments.

Trends in P Value, Confidence Interval, and Power Analysis Reporting in Health Professions Education Research Reports: A Systematic Appraisal.

PURPOSE: To characterize reporting of P values, confidence intervals (CIs), and statistical power in health professions education research (HPER) through manual and computerized analysis of published research reports. METHOD: The authors searched PubMed, Embase, and CINAHL in May 2016, for comparative research studies. For manual analysis of abstracts and main texts, they randomly sampled 250 HPER reports published in 1985, 1995, 2005, and 2015, and 100 biomedical research reports published in 1985 and 2015. Automated computerized analysis of abstracts included all HPER reports published 1970-2015. RESULTS: In the 2015 HPER sample, P values were reported in 69/100 abstracts and 94 main texts. CIs were reported in 6 abstracts and 22 main texts. Most P values (≥77%) were ≤.05. Across all years, 60/164 two-group HPER studies had ≥80% power to detect a between-group difference of 0.5 standard deviations. From 1985 to 2015, the proportion of HPER abstracts reporting a CI did not change significantly (odds ratio [OR] 2.87; 95% CI 1.04, 7.88) whereas that of main texts reporting a CI increased (OR 1.96; 95% CI 1.39, 2.78). Comparison with biomedical studies revealed similar reporting of P values, but more frequent use of CIs in biomedicine. Automated analysis of 56,440 HPER abstracts found 14,867 (26.3%) reporting a P value, 3,024 (5.4%) reporting a CI, and increased reporting of P values and CIs from 1970 to 2015. CONCLUSIONS: P values are ubiquitous in HPER, CIs are rarely reported, and most studies are underpowered. Most reported P values would be considered statistically significant.

Surgery Website as a 24/7 Adjunct to a Surgical Curriculum.

OBJECTIVE: Successfully teaching duty hour restricted trainees demands engaging learning opportunities. Our surgical educational website and its associated assets were assessed to understand how such a resource was being used. DESIGN: Our website was accessible to all Mayo Clinic employees via the internal web network. Website access data from April 2015 through October 2016 were retrospectively collected using Piwik. SETTING: Academic, tertiary care referral center with a large general surgery training program. Mayo Clinic, Rochester, MN. PARTICIPANTS: A total of 257 Mayo Clinic employees used the website. RESULTS: The website had 48,794 views from 6313 visits by 257 users who spent an average of 14 ± 11 minutes on the website. Our website houses 295 videos, 51 interactive modules, 14 educational documents, and 7 flashcard tutorials. The most popular content type was videos, with a total of 30,864 views. The most popular visiting time of the day was between 8 pm and 9 pm with 6358 views (13%), and Thursday was the most popular day with 17,907 views (37%).  A total of 78% of users accessed content beyond the homepage. Average visits peaked in relation to 2 components of our curriculum: a 240% increase one day before our biannual intern simulation assessments, and a 61% increase one day before our weekly conducted Friday simulation sessions. Interns who rotated on the service of the staff surgeon who actively endorses the website had 93% more actions per visit as compared to other users. The highest clicks were on the home banner for our weekly simulation session pre-emptive videos, followed by "groin anatomy," and "TEP hernia repair" videos. CONCLUSIONS: Our website acted as a "just-in-time" accessible portal to reliable surgical information. It supplemented the time sensitive educational needs of our learners by serving as a heavily used adjunct to 3 components of our surgical education curriculum: weekly simulation sessions, biannual assessments, and clinical rotations.

Needle Decompression of Tension Pneumothorax with Colorimetric Capnography.

BACKGROUND: The success of needle decompression for tension pneumothorax is variable, and there are no objective measures assessing effective decompression. Colorimetric capnography, which detects carbon dioxide present within the pleural space, may serve as a simple test to assess effective needle decompression. METHODS: Three swine underwent traumatically induced tension pneumothorax (standard of care, n = 15; standard of care with needle capnography, n = 15). Needle thoracostomy was performed with an 8-cm angiocatheter. Similarly, decompression was performed with the addition of colorimetric capnography. Subjective operator assessment of decompression was recorded and compared with true decompression, using thoracoscopic visualization for both techniques. Areas under receiver operating curves were calculated and pairwise comparison was performed to assess statistical significance (P < .05). RESULTS: The detection of decompression by needle colorimetric capnography was found to be 100% accurate (15 of 15 attempts), when compared with thoracoscopic assessment (true decompression). Furthermore, it accurately detected the lack of tension pneumothorax, that is, the absence of any pathologic/space-occupying lesion, in 100% of cases (10 of 10 attempts). Standard of care needle decompression was detected by operators in 9 of 15 attempts (60%) and was detected in 3 of 10 attempts when tension pneumothorax was not present (30%). True decompression, under direct visualization with thoracoscopy, occurred 15 of 15 times (100%) with capnography, and 12 of 15 times (80%) without capnography. Areas under receiver operating curves were 0.65 for standard of care and 1.0 for needle capnography (P = .002). CONCLUSIONS: Needle decompression with colorimetric capnography provides a rapid, effective, and highly accurate method for eliminating operator bias for tension pneumothorax decompression. This may be useful for the treatment of this life-threatening condition.

A Comparison of Objective Assessment Data for the United States and International Medical Graduates in a General Surgery Residency.

OBJECTIVE: To compare objective assessment scores between international medical graduates (IMGs) and United States Medical Graduates. Scores of residents who completed a preliminary year, who later matched into a categorical position, were compared to those who matched directly into a categorical position at the Mayo Clinic, Rochester. DESIGN: Postgraduate year (PGY) 1 to 5 residents participate in a biannual multistation, OSCE-style assessment event as part of our surgical training program. Assessment data were, retrospectively, reviewed and analyzed from 2008 to 2016 for PGY-1 and from 2013 to 2016 for PGY 2 to 5 categorical residents. SETTING: Academic medical center. PARTICIPANTS: Categorical PGY 1 to 5 General Surgery (GS) residents at Mayo Clinic Rochester, MN. RESULTS: A total of 86 GS residents were identified. Twenty-one residents (1 United States Medical Graduates [USMG] and 20 IMGs) completed a preliminary GS year, before matching into a categorical position and 68 (58 USMGs and 10 IMGs) residents, who matched directly into a categorical position, were compared. Mean scores (%) for the summer and winter multistation assessments were higher for PGY-1 trainees with a preliminary year than those without (summer: 59 vs. 37, p < 0.001; winter: 69 vs. 61, p = 0.05). Summer and winter PGY-2 scores followed the same pattern (74 vs. 64, p < 0.01; 85 vs. 71, p < 0.01). For the PGY 3 to 5 assessments, differences in scores between these groups were not observed. IMGs and USMGs scored equivalently on all assessments. Overall, junior residents showed greater score improvement between tests than their senior colleagues (mean score increase: PGY 1-2 = 18 vs. PGY 3-5 = 3, p < 0.001). CONCLUSIONS: Residents with a previous preliminary GS year at our institution scored higher on initial assessments compared to trainees with no prior GS training at our institution. The scoring advantage of an added preliminary year decreased as trainees progressed through residency.

The ACGME Case Log System May Not Accurately Represent Operative Experience Among General Surgery Interns.

OBJECTIVE: To assess if the Accreditation Council for Graduate Medical Education (ACGME) case log system accurately captures operative experience of our postgraduate year 1 (PGY-1) residents. DESIGN: ACGME case log information was retrospectively obtained for 5 cohorts of PGY-1 residents (2011-2015) and compared to the number of operative cases captured by an institutional automated operative case report system, Surgical Access Utility System (SAUS). SAUS automatically captures all surgical team members who are listed in the operative dictation for a given case, including interns. A paired t-test analysis was used to compare number of cases coded between the 2 systems. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: PGY-1 general surgery trainees (interns) from the years 2011-2015. RESULTS: Forty-nine PGY-1 general surgery residents were identified over a 5-year period. Mean operative case volume per intern, per year, captured by the automated SAUS was 176.5 ± 28.1 (SD) compared to 126.3 ± 58.0 ACGME cases logged (mean difference = 50.2 cases, p < 0.001). CONCLUSIONS: ACGME case log data may not accurately reflect the actual operative experience of our PGY-1 residents. If such data holds true for other general surgery training programs, the true impact of duty hour regulations on operative volume may be unclear when using the ACGME case log data. This current standard approach for using ACGME case logs as a representation of operative experience requires further scrutiny and potential revision to more accurately determine operative experience for accreditation purposes.

At Home Preresidency Preparation for General Surgery Internship: A Pilot Study.

OBJECTIVE: To create a novel "at-home" preresidency preparatory adjunct for medical students entering surgical residency. DESIGN: Preparatory resources were mailed to match medical students before residency matriculation in 2015. This included "how-to" videos, low-cost models, and surgical instruments for 5 "stations" (arterial blood gas analysis, anatomy and imaging knowledge, knot tying ability, and suturing dexterity) of our program's biannual general surgery intern objective assessment activity (Surgical Olympics: total 13 stations, 10 points each). Scores from 2015 were compared with 2014 historical controls in a retrospective manner using the Student's t-test. SETTING: Academic, tertiary care referral center with a large general surgery training program. PARTICIPANTS: Postgraduate year 1 general surgery trainees (interns) from the years 2014 and 2015. RESULTS: Twenty-six interns participated in the 2015 assessment and were compared to thirty-two 2014 interns. Overall mean scores were low, but higher (19.7 vs. 15.4, p = 0.04) in the 2015 class. The largest increase was noted in the anatomy knowledge station (mean = 5.0 vs. 1.9, p < 0.01). Scores in stations assessing technical competence were similar to controls. The number of perfect scores among the 5 stations was higher (10 vs. 5) in the 2015 group. Mean scores from the other 8 stations, for which no resources were mailed, showed no difference (29.3 vs. 28.3, p = 0.75). CONCLUSIONS: Enacting a simple, home-based curriculum for medical students before surgical residency, improved performance on early knowledge assessments.

Laparoscopic esophagomyotomy for achalasia in children: A review.

Esophageal achalasia in children is rare but ultimately requires endoscopic or surgical treatment. Historically, Heller esophagomyotomy has been recommended as the treatment of choice. The refinement of minimally invasive techniques has shifted the trend of treatment toward laparoscopic Heller myotomy (LHM) in adults and children with achalasia. A review of the available literature on LHM performed in patients < 18 years of age was conducted. The pediatric LHM experience is limited to one multi-institutional and several single-institutional retrospective studies. Available data suggest that LHM is safe and effective. There is a paucity of evidence on the need for and superiority of concurrent antireflux procedures. In addition, a more complete portrayal of complications and long-term (> 5 years) outcomes is needed. Due to the infrequency of achalasia in children, these characteristics are unlikely to be defined without collaboration between multiple pediatric surgery centers. The introduction of peroral endoscopic myotomy and single-incision techniques, continue the trend of innovative approaches that may eventually become the standard of care.

Catch me if you can early simulation efforts affect fundamental surgical skill assessment scores.

BACKGROUND: We evaluated whether early exposure to a simulation curriculum enhances acquired surgical skills. METHODS: The "Surgical Olympics" evaluates interns on basic surgical skills and knowledge. After the Summer Olympics (July), interns were randomly divided into groups: "A" participated in a 7-week curriculum once a week, whereas "B" attended 7 weeks of lectures once a week. All interns then participated in the October Olympics. The 2 groups then switched. Finally, all interns completed a January Olympics. RESULTS: Scores were tabulated for the July, October, and January Olympics. Mean scores (A = 182 ± 42, Group B = 188 ± 34; P = .70) were similar in July; in October, group A (mean score = 237 ± 31) outperformed group B (mean score = 200 ± 32; P = .01). Mean total scores in January (A = 290 ± 34, B = 276 ± 34; P = .32) were similar. CONCLUSIONS: Early exposure to a surgical simulation curriculum enhances surgical intern performance in our Surgical Olympics. Subsequent simulation experience helps learners close this gap.

Tube thoracostomy: Increased angle of insertion is associated with complications.

INTRODUCTION: Tube thoracostomy (TT), considered a routine procedure, has significant complications. Current recommendations for placement rely on surface anatomy. There is no information to guide operators regarding angle of insertion relative to chest wall. We aim to determine if angle of insertion is associated with complications of TT. METHODS: We performed a retrospective review of adult trauma patients who necessitated TT at a Level I trauma center over a 2-year period (January 2012 to December 2013). Tube thoracostomies performed intraoperatively or using radiological guidance were excluded. Thoracic anteroposterior or posteroanterior radiographs were reviewed to determine the angle of insertion of TT relative to the thoracic wall. A previously validated classification method was used to categorize complications. Descriptive and univariate statistics were used to compare angle of insertion and complicated versus uncomplicated TT. RESULTS: Review identified 154 patients who underwent a total of 246 TT placed for emergent trauma. All patients had a postprocedural chest x-ray. We identified 90 complications (37%) over the study period. One hundred forty-four of the TTs reviewed had an angle of insertion less than 45 degrees of which there were 27 complications (19%). One hundred two of the TTs had an angle greater than 45 degrees and 63 complications (62%); p < 0.0001. CONCLUSIONS: Tube thoracostomy insertion is inherently dangerous. Placement of TT using a higher angle of insertion greater than 45 degrees is associated with increased complications. Further prospective studies quantifying TT angle of insertion on outcomes are needed. LEVEL OF EVIDENCE: Therapeutic study, level IV.

Infected hardware after surgical stabilization of rib fractures: Outcomes and management experience.

BACKGROUND: Surgical stabilization of rib fracture (SSRF) is increasingly used for treatment of rib fractures. There are few data on the incidence, risk factors, outcomes, and optimal management strategy for hardware infection in these patients. We aimed to develop and propose a management algorithm to help others treat this potentially morbid complication. METHODS: We retrospectively searched a prospectively collected rib fracture database for the records of all patients who underwent SSRF from August 2009 through March 2014 at our institution. We then analyzed for the subsequent development of hardware infection among these patients. Standard descriptive analyses were performed. RESULTS: Among 122 patients who underwent SSRF, most (73%) were men; the mean (SD) age was 59.5 (16.4) years, and median (interquartile range [IQR]) Injury Severity Score was 17 (13-22). The median number of rib fractures was 7 (5-9) and 48% of the patients had flail chest. Mortality at 30 days was 0.8%. Five patients (4.1%) had a hardware infection on mean (SD) postoperative day 12.0 (6.6). Median Injury Severity Score (17 [range, 13-42]) and hospital length of stay (9 days [6-37 days]) in these patients were similar to the values for those without infection (17 days [range, 13-22 days] and 9 days [6-12 days], respectively). Patients with infection underwent a median (IQR) of 2 (range, 2-3) additional operations, which included wound debridement (n = 5), negative-pressure wound therapy (n = 3), and antibiotic beads (n = 4). Hardware was removed in 3 patients at 140, 190, and 192 days after index operation. Cultures grew only gram-positive organisms. No patients required reintervention after hardware removal, and all achieved bony union and were taking no narcotics or antibiotics at the latest follow-up. CONCLUSIONS: Although uncommon, hardware infection after SSRF carries considerable morbidity. With the use of an aggressive multimodal management strategy, however, bony union and favorable long-term outcomes can be achieved. LEVEL OF EVIDENCE: Therapeutic study, level V.

Adenomas of the ampulla of Vater: a comparison of outcomes of operative and endoscopic resections.

BACKGROUND: Data comparing operative and endoscopic resection of adenomas of the ampulla of Vater are limited. Our aims were to evaluate and compare the long-term results and outcomes of endoscopic and operative resections of benign tumors of the ampulla of Vater as well as to determine which features of benign periampullary neoplasms would predict recurrence or failure of endoscopic therapy and therefore need for operative treatment. METHODS: Retrospective review of all patients treated for adenomas of ampulla of Vater at our institution from 1994 to 2009. RESULTS: Over a 15-year span, 180 patients (mean age 59 years) were treated for benign adenomas of the ampulla of Vater with a mean follow-up of 4.4 years. Obstructive jaundice was more common in the operative resection group (p = 0.006). The adenomas were tubular in 83 patients (44%), tubulovillous in 77 (45%) and villous in 20 (11%). Endoscopic resection alone was performed in 130 patients (78%). Operative resection was performed in 50 patients (28%), with pancreatoduodenectomy in 40, transduodenal local resection in 9, and pancreas-sparing total duodenectomy in 1. Nine patients who underwent endoscopic resection initially were endoscopic treatment failures. Fifty-eight percent of endoscopically treated patients required one endoscopic resection, while 58 (42%) required two or more endoscopic resections (range 2-8). Patients who underwent operative resection had larger tumors with a mean size of 3.7 ± 2.8 versus 1.8 ± 1.5 cm in those treated by endoscopic resection (p < 0.001) or intraductal extension (p = 0.02). Intraductal extension and ulceration had no effect on recurrence if completely resected endoscopically (p = 0.41 and p = 0.98, respectively). Postoperative complications occurred in 58% of patients, and post-endoscopic complications in 29% (p < 0.001). Endoscopic resection was associated with a greater than fivefold risk of recurrence than operative resection (p = 0.006); 4% of recurrences had invasive carcinomas. When comparing patients who underwent local resections only (endoscopic and operative), there was no difference in the recurrence rate between endoscopic resection and operative transduodenal resection (32 versus 33%; p = 0.49). The need for two or more endoscopic resections for complete tumor removal was associated with 13-fold greater risk of recurrence (p < 0.001). CONCLUSION: There is no significant difference between endoscopic and local operative resections of benign adenomas of ampulla of Vater; recurrences are more common when two or more endoscopic resections are required for complete tumor removal. Appropriate adenomas for endoscopic resection included tumors <3.6 cm that do not extend far enough intraductally (on EUS) to preclude an endoscopic snare ampullectomy.