Fuad Alkhoury

The Impact of Laparoscopy on the Volume of Open Cases in General Surgery Training

OBJECTIVE The purpose of this study was to evaluate the impact of laparoscopy on the volume of open cases in general surgery residency training over the past 10 years. DESIGN The Accreditation Council for Graduate Medical Education (ACGME) database (1999-2008), which records all cases (by Current Procedural Terminology code) performed by graduating general surgery trainees, was retrospectively analyzed. SETTING ACGME database (1999-2008). MAIN OUTCOME MEASURES Trends were compared regarding the average number of the most common laparoscopic and open procedures (colectomy, hernia, and appendectomy) performed by graduating general surgery trainees during the reporting period. RESULTS Across all procedures, an increase was noted in laparoscopic approaches with a reciprocal decrease in open cases. The number of open appendectomies decreased by 29% (30.7 to 21.7), whereas the number of laparoscopic appendectomies increased by 278% (8.5 to 32.1). Similarly, open inguinal hernia cases decreased by 12.5% (51.9 to 45.4) and open colectomy cases decreased by 10.4% (48 to 43). Conversely, laparoscopic hernia repair and laparoscopic colectomy increased by 87.5% (7.6 to 15.8) and 550% (2 to 13), respectively. CONCLUSIONS In addition to the limitations placed on residency training by other factors (including work hour restrictions), changing practice patterns within the field of general surgery have a significant impact on the exposure of residents to open surgery cases. This trend might have far-reaching implications with regard to the overall competency of graduating residents and raises concerns for the future direction of surgical education.

Cost and clinical outcomes of laparoscopic ventral hernia repair using intraperitoneal nonheavyweight polypropylene mesh.

Background There are a variety of different products available for laparoscopic ventral hernia repairs (LVHR), which vary widely in their costs. There are few clinical studies commenting on cost efficacy of LVHR. The objective of this study is to investigate the cost, safety, and efficacy of using intraperitoneal nonheavyweight polypropylene (PP) mesh in LVHR. Methods Between the years 2002 and 2006, LVHR was performed in 141 consecutive patients (84 male, 57 female) using intraperitoneal PP. Using a 3-trocar technique, PP mesh was underlayed by 3 to 5 cm beyond the edges of the hernia defect and fixed to the abdominal wall with 2 rows of titanium staples. Data concerning the demographics of patients, mesh cost, operative time, length of hospital stay, and complications were collected. Results One hundred thirty-four patients (95%) were discharged on the day of surgery. Mean age was 58.7 years (range, 29 to 91 y). Mean operative time was 63 minutes (range, 34 to 124 min). Follow-up was achieved in 123 patients (87%) with a mean of 40 months (range, 12 to 68 mo). The average mesh size was 256.9 cm2 (range, 116 to 903 cm2). The cost of the PP mesh was US

Abdominal Aortic Aneurysm Repair Complicated by Infection With Clostridium septicum

0.14 per cm2. The average mesh cost per patient was

Esophageal granular cell tumor colliding with intramucosal adenocarcinoma: a case report

35.90. When compared with other meshes commonly used for LVHR, PP mesh was substantially cheaper with a cost saving of

Metastatic adenocarcinoma within a functioning adrenal adenoma: a case report

436 per patient with proceed,

Early Postoperative Hemorrhage After Open and Laparoscopic Roux-En-Y Gastric Bypass

770 per patient with composix, and

'Normal' Vital Signs Belie Occult Hypoperfusion in Geriatric Trauma Patients

931 per patient with polytetrafluoroethylene. The postoperative complications included: Wound infection n=4 (3.2%), transient partial small bowel obstruction which resolved in all cases without operative management n=3 (2.4%), port site hernia n=2 (1.6%), and seroma n=1 (0.7%). Overall recurrence rate was n=6 (4.8%). There were no conversions to an open procedure. Conclusions LVHR with intraperitoneal PP results in outcomes comparable with earlier publications on LVHR but at reduced costs. These data suggest that the use of intraperitoneal PP in LVHR is safe and cost effective.

Clinical pulmonary embolus after gastric bypass surgery

Aortic stent-graft infection after endovascular abdominal aortic aneurysm (AAA) repair is an uncommon, but very serious complication with potentially devastating consequences.(1) Traditional open techniques of repair of AAA demonstrate an infection rate of 0.5-3%. The exact rate of infection with endovascular repair is unknown, but literature review demonstrates an overall incidence of 0.43-1.17% retrospectively.(2,3) Etiology of endovascular graft infections typically results from flora derived from the skin or gastrointestinal tract.(4)Clostridium septicum is a naturally occurring anaerobic bacterium native to the gastrointestinal tract. It is typically associated with spontaneous nontraumatic gas gangrene owing to bacteremia from the gastrointestinal tract with an incidence rate of 0.07%.(5) To our knowledge, this is the first reported case of endovascular AAA graft infection owing to Clostridium septicum species.

Outcomes after Severe Head Injury: A National Trauma Data Bank-Based Comparison of Level I and Level II Trauma Centers

We report a case of a granular cell tumor colliding with intramucosal adenocarcinoma of the esophagus. A 58-year-old white was found to have a 5 mm nodule in the distal esophagus detected by upper gastrointestinal endoscopy performed as part of the workup of long standing reflux. Endoscopic biopsies revealed intramucosal adenocarcinoma arising in the setting of Barretts esophagus. The adenocarcinoma infiltrated a granular cell tumor also present at the nodular site. Endoscopic mucosal resection using Duette band ligation and hot snare electrocautery was performed. Margins were negative for both tumors, and endoscopic surveillance for recurrence is planned.

Recombinant factor VIIa: hemostatic adjunct in the coagulopathic burn patient.

We present the case of a 54-year-old woman who underwent right adrenalectomy for palliation of Cushings symptoms. She had recently been diagnosed with lung adenocarcinoma. Pathologic findings revealed a 5 cm adrenal adenoma with a metastatic adenocarcinoma deposit. The occurrence of tumor-to-tumor metastasis is rare, and the finding of a metastasis within a functional adrenal adenoma exceptionally so. Previously reported incidences of this finding in patients with lung cancer range from 0.14% to 0.63%. We review the literature regarding this unusual finding.