Daniel T Farkas

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.

Gallstone ileus with multiple stones: Where Rigler triad meets Bouveret's syndrome.

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouverets syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Carcinoma in situ in a 7 mm gallbladder polyp: Time to change current practice?

Detection of polypoid lesions of the gallbladder is increasing in conjunction with better imaging modalities. Accepted management of these lesions depends on their size and symptomatology. Polyps that are symptomatic and/or greater than 10 mm are generally removed, while smaller, asymptomatic polyps simply monitored. Here, a case of carcinoma-in-situ is presented in a 7 mm gallbladder polyp. A 25-year-old woman, who had undergone a routine cholecystectomy, was found to have an incidental 7 mm polyp containing carcinoma in situ. She had few to no risk factors to alert to her condition. There are few reported cases of cancer transformation in gallbladder polyps smaller than 10 mm reported in the literature. The overwhelming consensus, barring significant risk factors for cancer being present, is that such lesions should be monitored until they become symptomatic or develop signs suspicious for malignancy. In our patients case this could have led to the possibility of missing a neoplastic lesion, which could then have gone on to develop invasive cancer. As gallbladder carcinoma is an aggressive cancer, this may have led to a tragic outcome.

Laparoscopic removal of migrated intrauterine device embedded in intestine.

Introduction: The intrauterine device (IUD) is a popular family planning method worldwide. Some of the complications associated with insertion of an IUD are well described in the literature. The frequency of IUD perforation is estimated to be between 0.05 and 13 per 1000 insertions. There are many reports of migrated intrauterine devices, but far fewer reports of IUDs which have penetrated into the small intestine. Case Description: Herein we report a case of perforated intrauterine device embedded in the small intestine. By using a wound protector retraction device, and fashioning the anastomosis extra-corporeally, we were able to more easily perform this laparoscopically. This left the patient with a quicker recovery, and a better cosmetic result. Discussion: IUD perforation into the peritoneal cavity is a known complication, and necessitates close follow-up. Most, if not all, should be removed at the time of diagnosis. In the majority of previously reported cases, removal was done through laparotomy. Even in cases where removal was attempted laparoscopically, many were later converted to laparotomy. Surgeons should be aware of different techniques, including using a wound protector retraction device, in order to facilitate laparoscopic removal.

Minimally Invasive Management of Biliary Tract Injury Following Percutaneous Nephrolithotomy

Introduction: Percutaneous nephrolithotomy is generally considered a safe option for the management of large complex or infectious upper urinary tract calculi. Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality, especially in cases where biliary peritonitis develops. All reported cases of biliary tract injury have been managed by either open or laparoscopic cholecystectomy. Case Presentation: Herein for the first time, we report a 39-year old woman with biliary tract injury following percutaneous nephrolithotomy who was managed less invasively by insertion of a percutaneous cholecystostomy tube. The patient was discharged home shortly thereafter, and the tube was later removed at a follow up visit after a normal cholangiogram. Conclusions: Biliary tract injury is a rare and potentially serious complication of percutaneous nephrolithotomy that can even lead to mortality. If a biliary tract injury is suspected during percutaneous renal procedures, diverting the bile away from the leak may resolve the problem without the need for a cholecystectomy. Ideally this can be done with ERCP and a stent, but in cases where this is not technically feasible; a percutaneous cholecystostomy can be successful at accomplishing the same result.

The effect of insurance status on the stage of colorectal cancer at diagnosis.

420 Background: There is currently a lot of focus on the number of uninsured patients in the country. Part of the recent healthcare debate revolved around the lack of preventative medicine and screening in such patients. The assumption is that patients without insurance present to hospitals with later stages of disease. The purpose of this study was to evaluate patients with colorectal cancer, and to see if their insurance status was related to the stage of their cancer at diagnosis. METHODS All patients in our tumor registry with a diagnosis of colorectal cancer between 2000 and 2010 were initially included. Those who did not have their complete care in our hospital, or those for whom insurance information was not available, were excluded. Patients were categorized into insured and uninsured patients. Cancer staging at the time of diagnosis was done according to the American Joint Committee on Cancer guidelines, and patients with stage 3 or 4 disease were classified as having advanced cancer. RESULTS There were 489 patients in the tumor registry for these ten years, of which 435 had their care in our hospital and were fully staged. Insurance information was available for 383 patients (88%). There were 360 patients (94.0%) in the insured group and 23 patients (6.0%) in the uninsured. In the insured group there were 128 patients (33.4%) with advanced cancer, while in the uninsured group there were 15 patients (65.2%). This difference was highly significant (Chi-square, p=0.007). CONCLUSIONS Patients without insurance present with more advanced stages of colorectal cancer. In our series, uninsured patients were almost twice as likely to present with stage 3 or 4 disease. Efforts at helping more patients gain access to healthcare insurance could perhaps lead to fewer people presenting with advanced stages of cancer.