Ajay Shah

Case Report: Paraganglioma of the Pancreas

Extraadrenal paragangliomas are very rare tumors arising from cells derived from the neural crest. These tumors are encountered only as case reports, and as a result, little is known of their natural history. We present a case of pancreatic paraganglioma and review all previously reported cases.Paraganglioma, or extraadrenal pheochromocytomas, arise from paraganglia and are histologically akin to chemodectomas. They are rare, affecting about one in 2,000,000 people (1). Paragangliomas are essentially neural cells that have separated from developing autonomic ganglia. Hence, like autonomic ganglia, paraganglia are also found within organs (2). A paraganglioma arising from a visceral organ is exceedingly rare.

Cystic Hypersecretory Duct Carcinoma of the Breast

Abstract: We present two cases of a rare form of intraductal carcinoma of the breast, “cystic hypersecretory carcinoma of the breast.” The clinical and pathologic characteristics of the lesion are discussed, along with a review of the literature.

Laparoscopic vs open partial colectomy in elderly patients: Insights from the American College of Surgeons - National Surgical Quality Improvement Program database

AIM To compare the outcomes between the laparoscopic and open approaches for partial colectomy in elderly patients aged 65 years and over using the American College of Surgeons - National Surgical Quality Improvement Program (ACS NSQIP) database. METHODS The ACS NSQIP database for the years 2005-2011 was queried for all patients 65 years and above who underwent partial colectomy. 1:1 propensity score matching using the nearest- neighbor method was performed to ensure both groups had similar pre-operative comorbidities. Outcomes including post-operative complications, length of stay and mortality were compared between the laparoscopic and open groups. χ(2) and Fishers exact test were used for discrete variables and Students t-test for continuous variables. P < 0.05 was considered significant and odds ratios with 95%CI were reported when applicable. RESULTS The total number of patients in the ACS NSQIP database of the years 2005-2011 was 1777035. We identified 27604 elderly patients who underwent partial colectomy with complete data sets. 12009 (43%) of the cases were done laparoscopically and 15595 (57%) were done with open. After propensity score matching, there were 11008 patients each in the laparoscopic (LC) and open colectomy (OC) cohorts. The laparoscopic approach had lower post-operative complications (LC 15.2%, OC 23.8%, P < 0.001), shorter length of stay (LC 6.61 d, OC 9.62 d, P < 0.001) and lower mortality (LC 1.6%, OC 2.9%, P < 0.001). CONCLUSION Even after propensity score matching, elderly patients in the ACS NSQIP database having a laparoscopic partial colectomy had better outcomes than those having open colectomies. In the absence of specific contraindications, elderly patients requiring a partial colectomy should be offered the laparoscopic approach.

Medical student perception of night call in a night float system

BACKGROUND Because of work hour regulations, many surgical residency programs have moved to a night float system. Previously, our medical students took call for 24 hours, whereas currently they also follow a night float system. This study looked at their evaluations of these 2 systems. METHODS Students were anonymously surveyed to evaluate the rotation (on a 5-point scale) as well as various components including night call. Responses from each group were compared. RESULTS There were 104 students included: 46 in the traditional 24-hour call group and 58 in the night float group. Students rated night call significantly higher in the night float system (4.62 ± .64 vs 3.52 ± 1.00, P < .001). There was no difference in the other components or the overall evaluation. CONCLUSIONS After switching to a night float system, students had a much more positive perception of their night call experience. We believe more clerkships should switch to a night float system.

The Use of a Surgery-Specific Written Examination in the Selection Process of Surgical Residents

OBJECTIVE Selection of surgical residents is a difficult task, and program directors are interested in identifying the best candidates. Among the qualities being sought after is the ability to acquire surgical knowledge, and eventually do well on their board examinations. During the interview process, many programs use results from the United States Medical Licensing Exam (USMLE) to identify residents they think will do well academically. The purpose of this study was to evaluate a different method of identifying such residents, through the use of a surgery-specific written exam (SSWE). DESIGN A retrospective review of residents in our program between 2004 and 2012 was done. A 50-question SSWE was designed and administered to candidates on the day of their interview. Scores on the SSWE and the USMLE were compared with results on the American Board of Surgery In-Training Exam (ABSITE). Correlation coefficients were calculated and compared. SETTING Community based General Surgery residency program. PARTICIPANTS Resident applicants. RESULTS Forty-three residents had scores available from the SSWE, USMLE Part 1 (USMLE-1), and Part 2 (USMLE-2). There were ABSITE scores available for 38 in postgraduate year (PGY) 1. USMLE-1 had a statistically significant correlation (r = 0.327, p = 0.045) with the ABSITE score in PGY-1 (ABSITE-1), while with USMLE-2 had slightly less correlation (r = 0.314, p = 0.055) with ABSITE-1. However, the SSWE had a much stronger correlation (r = 0.656, p < 0.001) than either of them. CONCLUSIONS An SSWE is a good method to identify residents who will later do well on the ABSITE. It is a better method than using the more general USMLE. Since the ABSITE has been shown to correlate with performance on board examinations, residency programs interested in identifying candidates that will do well on their board examinations, should consider incorporating an SSWE into their application process.

Marginal zone lymphoma of the breast-A diminished role for surgery.

Highlights • Very sparse literature exists that describe the clinical profile of primary MZL of breast.• Radiotherapy alone might cure an indolent lymphoma localized to breast (i.e. stage IE).• 5-yr survival rates of surgery are inferior to radiotherapy and chemo-radiation.• Greater appreciation of the lesser role of surgery is warranted.

A rare cause of small bowel obstruction due to bezoar in a virgin abdomen

Highlights • Bezoar-induced small bowel obstruction remains an uncommon diagnosis accounting for 0.4–4% of all mechanical bowel obstruction that poses a diagnostic and management challenge.• It should be suspected in patients with an increased risk of bezoar formation, such as in the presence of previous gastric surgery, poor dentition or a history suggestive of increased fiber intake, or patient with psychiatric disorders.• The presence of well-defined intraluminal mass with mottled gas pattern on CT scan is suggestive of an intestinal bezoar.

Caution Ahead: Research Challenges of a Randomized Controlled Trial Implemented to Improve Breast Cancer Treatment at Safety-Net Hospitals

PURPOSE To implement and test a Web-based tracking and feedback (T&F) tool to close referral loops and reduce adjuvant breast cancer treatment underuse in safety-net hospitals (SNHs). PATIENT AND METHODS We randomly assigned 10 SNHs, identified patients with new stage 1 to stage 3 breast cancer, assessed their connection with the oncologist, and relayed this information to surgeons for follow-up. We interviewed key informants about the tools usefulness. We conducted intention-to-treat and pre- and poststudy analyses to assess the T&F tool and implementation effectiveness, respectively. RESULTS Between the study start and intervention implementation, several hospitals reorganized care delivery and 49% of patients scheduled to undergo breast cancer surgery were ineligible because they already were in contact with an oncologist. One high-volume hospital closed. Despite randomization of hospitals, intervention (INT) hospitals had fewer white patients (5% v 16%; P = .0005), and more underuse (28% v 15%; P = .002) compared with usual care (UC) hospitals. Over time, INT hospitals with poorer follow-up significantly reduced underuse compared with UC hospitals (INT hospitals, from 33% to 9%, P = .001 v UC hospitals, from 15% to 11%, P = .5). There was no difference in underuse (9% at INT hospitals, 11% at UC hospitals; P = .8). Hospitals with better follow-up (odds ratio, 0.85; 95% CI, 0.73 to 0.98) had less underuse. In settings with poor follow-up and tracking approaches, key informants found the tool useful. The rapidly changing delivery landscape posed significant challenges to this implementation research. CONCLUSION A T&F tool did not significantly reduce adjuvant underuse but may help reduce underuse in SNHs with poor follow-up capabilities. Inability to discern T&F effectiveness is likely due to encountered challenges that inform lessons for future implementation research.

Unusual Lesions in the Breast – Recurrent Metastasis in the Breast from Uterine Sarcoma

with abundant quantities of eosinophilic cytoplasm and a few binucleate cells. Immunohistochemically the cells were positive for desmin and vimentin (Fig. 1). CT, US and histopathological findings confirmed diagnosis as rhabdomyosarcoma (RMS) of the maxillary sinus, alveolar subtype metastasizing to breast and lung. RMS is a malignant soft tissue tumor of rhabdomyoblasts usually occurring in adolescent females 12– 20 years of age and breast metastases are rare. The most common primary sites are extremities and the trunk but rare in the maxillary sinus. The two main histological variants of RMS are embryonal and alveolar. RMS with breast metastases invariably had metastases in more than one site commonly the lungs, distant lymph nodes and skin.

PhytobezoarInduced Small Bowel Obstruction in a Young Male with Virgin Abdomen

Phytobezoars are a rare cause of small bowel obstruction. Such cases are most commonly associated with previous abdominal surgery or poor dentition or psychiatric conditions. A 40 year old man with a virgin abdomen and excellent dentition and no underlying psychiatric condition presented with an acute abdomen. CT scan revealed a transition point between dilated proximal loops of small bowel and collapsed distal loops. Exploratory laparotomy revealed a phytobezoar unable to be milked into the cecum and an enterectomy with primary anastamosis was performed without complication. A detailed history revealing several less common predisposing factors for phytobezoars should increase clinical suspicion of a phytobezoarinduced small bowel obstruction in the setting of an acute abdomen. Vigilance in presentations of an acute abdomen improves the usefulness of medical imaging, such as a CT, to detect phytobezoars. Understanding mechanisms of phytobezoar formation helps guide management and may prevent surgery.