David Y. Lee

Surgical Residents' Perception of the 16-Hour Work Day Restriction: Concern for Negative Impact on Resident Education and Patient Care

BACKGROUND Effective July 1, 2011, the Accreditation Council for Graduate Medical Education (ACGME) instituted a 16-hour duty period limitation for postgraduate year I (PGY I) residents. Our aim was to assess the attitudes and perception of general surgery residents regarding the new duty hour limitation as well as the transfer of care process under the new guidelines. STUDY DESIGN An anonymous, web-based survey was conducted nationally 7 months after the institution of the 16-hour duty limitation. RESULTS A total of 464 completed surveys were analyzed. Overall, 75% of residents expressed dissatisfaction with the new duty hour limitation. PGY II to V residents reported a higher level of dissatisfaction compared with PGY I residents (87% vs 54%, p < 0.01). Eighty-nine percent of PGY II to V residents responded that there has been a shift of responsibilities from the PGY I class to PGY II to V residents, with 73% reporting increased fatigue as a result. Seventy-five percent of PGY I and 94% of PGY II to V residents expressed concerns about the adverse impact of the restrictions on the education of PGY I residents (p < 0.01). Residents at all PGY training levels reported encountering problems due to inadequate sign-outs (PGY I, 59%; PGY II to V, 85%; p < 0.01). Sixty-two percent of PGY I residents and 54% of PGY II to V residents believed that the new 16-hour duty restriction contributes to inadequate sign-outs (p = NS). Most PGY II to V residents (86%) believe there is a decreased level of patient ownership due to the work hour restrictions. CONCLUSIONS The results of the survey suggest that the majority of general surgery residents are concerned over the potential negative impact of the duty limitation on resident education and patient care. Further research is needed to address these concerns.

Predictors of mortality after emergency colectomy for Clostridium difficile colitis: an analysis of ACS-NSQIP.

Objective:To evaluate clinical factors associated with mortality in emergency colectomies performed for Clostridium difficile colitis. Background:The incidence and mortality from C difficile colitis is on the rise. Emergent colectomy performed for C difficile colitis is associated with a high mortality. Methods:The ACS-NSQIP database from 2005 to 2010 was used to study emergently performed open colectomies for a primary diagnosis of C difficile colitis on the International Classification of Diseases, Ninth Revision. Preoperative, intraoperative, and postoperative factors were noted and compared between survivors and nonsurvivors. We performed multivariate stepwise binomial logistic regression analyses to study clinical factors that may be associated with 30-day mortality. Results:The overall mortality for this cohort was 33% (111/335) with a median time to death of 8 days. On average, survivors were discharged on postoperative day 24. On multivariate analysis, those aged 80 years or older were associated with a ninefold increase in the odds of mortality [95% confidence interval (CI): 3.0–13.0]. Other factors associated with increased mortality were preoperative shock (OR = 2.8, 95% CI: 1.6–5.4), preoperative dialysis dependence (OR = 2.3, 95% CI: 1.1–4.8), chronic obstructive pulmonary disease (OR = 3.7, 95% CI: 2.0–7.1), and wound class III (OR = 2.1, 95% CI: 3.0–13). Thrombocytopenia (platelet count < 150 × 103/mm3), coagulopathy (International Normalized Ratio >2.0), and renal insufficiency (blood urea nitrogen > 40 mg/dL) were associated with a higher mortality as well. Conclusions:This is the largest series of colectomies performed for C difficile colitis in the literature. We identified several preoperative clinical risk factors that were associated with increased postoperative mortality. These findings may be useful in selecting appropriate patients for surgical intervention and may help to define a population where surgery may not be beneficial.

Outcomes of pancreaticoduodenectomy for pancreatic malignancy in octogenarians: an American College of Surgeons National Surgical Quality Improvement Program analysis.

BACKGROUND Most series analyzing outcomes of pancreaticoduodenectomy in octogenarians are limited by a small sample size. The investigators used the American College of Surgeons National Surgical Quality Improvement Program database for an analysis of the impact of advanced age on outcomes after pancreatic cancer surgery. METHODS The National Surgical Quality Improvement Program database from 2005 to 2010 was accessed to study the outcomes of 475 pancreaticoduodenectomies performed in patients ≥80 years of age compared with 4,102 patients <80 years of age using chi-square and Students t tests. A multivariate logistic regression was used to analyze factors associated with 30-day mortality and the occurrence of major complications. RESULTS Octogenarians had significantly more preoperative comorbidities compared with patients <80 years of age. On multivariate analysis, age ≥80 years was associated with an increased likelihood of experiencing 30-day mortality and major complications compared with patients <80 years of age. On subgroup analysis, septuagenarians had a similar odds ratio of experiencing mortality or complications compared with octogenarians, whereas patients <70 years of age were at lower risk. CONCLUSIONS Although octogenarians have an increased risk for mortality and major complications compared with patients <80 years of age, on subgroup analysis, they do not differ from septuagenarians.

Feasibility and analgesic efficacy of the transversus abdominis plane block after single-port laparoscopy in patients having bariatric surgery.

Purpose The transversus abdominis plane (TAP) block is a technique increasingly used for analgesia after surgery on the anterior abdominal wall. We undertook this study to determine the feasibility and analgesic efficacy of ultrasound-guided TAP blocks in morbidly obese patients. We describe the dermatomal spread of local anesthetic in TAP blocks administered, and test the hypothesis that TAP blocks decrease visual analog scale (VAS) scores. Patients and methods After ethics committee approval and informed consent, 35 patients with body mass index >35 undergoing single-port sleeve gastrectomy (SPSG) were enrolled. All patients received balanced general anesthesia, followed by intravenous patient-controlled analgesia (IV-PCA; hydromorphone) postoperatively; all reported VAS >3 upon arrival to the recovery room. From the cohort of 35 patients having single-port laparoscopy (SPL), a sealed envelope method was used to randomly select ten patients to the TAP group and 25 patients to the control group. The ten patients in the TAP group received ultrasound-guided TAP blocks with 30 mL of 0.2% Ropivacaine injected bilaterally. The dermatomal distribution of the sensory block (by pinprick test) was recorded. VAS scores for the first 24 hours after surgery and opioid use were compared between the IV-PCA+TAP block and IV-PCA only groups. Results Sensory block ranged from T5–L1. Mean VAS pain scores decreased from 8 ± 2 to 4 ± 3 (P=0.04) within 30 minutes of TAP block administration. Compared with patients given IV-PCA only, significantly fewer patients who received TAP block had moderate or severe pain (VAS 4–10) after block administration at 6 hours and 12 hours post-surgery. However, cumulative consumption of hydromorphone at 24 hours after SPSG surgery was similar for both groups. Conclusion Ultrasound-guided TAP blocks in morbidly obese patients are feasible and result in satisfactory analgesia following SPSG in the immediate postoperative period.

Socioeconomic and Geographic Differences in Immediate Reconstruction after Mastectomy in the United States

Disparities are evident in breast cancer diagnosis, treatment, and outcomes. This study examines multiple socioeconomic and geographic regions across the US to determine if disparities exist in the type of reconstruction obtained after mastectomy. This is a retrospective study evaluating socioeconomic and geographic variables of 14,764 women who underwent mastectomy in 2008 using the Nationwide Inpatient Sample (NIS). Statistical analysis was performed on three groups of women: patients without reconstruction (NR), patients who underwent breast implant/tissue expander reconstruction (TE), and patients with autologous reconstruction such as free or pedicled flaps (FLAP). The majority of patients (63.9%) had NR, while 23.9% had TE and 12.2% underwent FLAP. Compared to patients with NR, women with TE or FLAP were younger (64.9 years versus 51.3 and 51.1 years, p < 0.001), had fewer chronic conditions (2.60 and 2.54 chronic conditions for TE and FLAP respectively versus 3.85 for NR, p < 0.001) and higher mean hospital charges (

Multi‐Centric Breast Cancer Involving a Ventriculoperitoneal Shunt

42,850 TE and

The effects of neoadjuvant chemoradiation on pancreaticoduodenectomy—the American College of Surgeon's National Surgical Quality Improvement Program analysis

48,680 FLAP versus

Primary lymph node gastrinoma. A diagnosis of exclusion. A case for duodenotomy in the setting of a negative imaging for primary tumor: A case report and review of the literature

22,300 NR, p < 0.001). Both Medicare and Medicaid insurance carriers had a higher proportion of women that did not get reconstructed compared to other insurance types (p < 0.001). Compared to NR, reconstructed women more often lived in urban areas and zip codes with higher average incomes (p < 0.001). This is the first national study analyzing insurance type and geographic variations to show statistically significant disparities in rate and type of immediate reconstruction after mastectomy. These inequalities need to be addressed to extend immediate reconstruction options to all women undergoing mastectomy.

Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis.

An 88-year-old female with significant dementia presented to the breast clinic with a hard skin lesion on the right breast, and bilateral calcifications on her annual mammogram. Available records indicate lack of a personal or family history of breast cancer. Physical examination revealed a raised, slightly erythematous, firm skin lesion which measured approximately 1.5 cm, located 7 cm from the nipple at the 1 o’clock position. Approximately 2 cm in length of catheter was palpated superior to this skin Figure 2. Sequential MR images of right breast nodular tumor (1.6 · 1.2 · 1.3-cm) (within circle) before (a: left upper), during (b: right upper) and after(c: left lower) chemotherapy. The pictures showed only slightly reduce gray color areas of the lesion. (d) It shows adenomyoepithelioma of the breast after chemotherapy, which composed mainly of proliferative myoepithelial cells (straight arrows) and a few epithelial cells (curve white arrows). The myoepithelial cells are obvious cytological atypia with large vesicular nuclei and prominent nucleoli and associate high mitotic activity (approximately 10 ⁄ 10 HPF) (straight arrows).

The Significance of Lobular Carcinoma In Situ and Atypical Lobular Hyperplasia of the Breast

BACKGROUND The purpose of this study was to investigate the effects of preoperative chemoradiation therapy on postoperative outcomes of pancreaticoduodenectomy (PD). MATERIALS AND METHODS The American College of Surgeons National Surgical Quality Improvement Program Participant User File from 2005-2011 was used to analyze the outcomes of patients who underwent chemoradiation therapy before PD. Their outcomes were compared with those who underwent PD without neoadjuvant therapy. RESULTS We identified 110 patients who received preoperative chemoradiation therapy before undergoing PD for pancreatic malignancies and compared them with 4915 patients who did not. The two groups were similar in their preoperative comorbidities and demographics. The neoadjuvant group experienced a significantly longer operative time with a higher rate of vascular reconstruction, transfusion requirement, and superficial wound infection compared with those who did not receive neoadjuvant therapy. However, mortality and the rate of major complications between the two groups were similar. CONCLUSIONS Preoperative chemoradiation therapy is associated with an increase in transfusion requirement and superficial surgical site infection. However, it is not associated with an increase in 30-d mortality or major complications.