Vijay K. Maker

Improving outcomes on the ABS Certifying Examination: can monthly mock orals do it?

PURPOSE First-time pass rates on the American Board of Surgery Certifying Examination (ABSCE) have now become one of the standards of excellence to evaluate residency programs. Our residency program started monthly simulated and critiqued (verbal, written, and video) oral examinations (MSCE) in 2003. The current study explores the outcomes of this intervention. METHODS We evaluated ABSCE performance of 48 residents who graduated from a large academic/community program between the years 2001 and 2006 though a prospective study with historical controls. Residents were divided into 2 groups: The intervention group comprised the 2003 to 2006 classes, which underwent MSCE; the historical control group spanned the 2001 and 2002 classes, which did not undergo MSCE. Results in the ABSCE were compared between groups using the Fisher exact test. In addition, the intervention group was queried in relation to the most important aspects of the MSCE as a learning experience through a structured questionnaire. RESULTS A statistically significant improvement (p = 0.038) in ABSCE first-time pass rates was noted in the intervention group. Examinees unanimously asserted they had been helped by the MSCE. Improvements in clinical reasoning and promotion of self-study were the most often cited benefits of the MSCE. CONCLUSION Monthly simulated and critiqued oral examinations improved the first-time pass rate of the American Board of Surgery Certifying Examination. Additional perceived benefits of this intervention included improvements in clinical reasoning and promotion of self-study.

Survival after resection of cutaneous adnexal carcinomas with eccrine differentiation: Risk factors and trends in outcomes

Current staging systems do not specifically address cutaneous adnexal carcinomas with eccrine differentiation. Due to their rarity, prognosis and management strategies are not well established. A population‐based study was performed to determine prognostic factors and survival.

Changing paradigms of seat belt and air bag injuries: what we have learned in the past 3 decades

This commentary article explores the impact of the use of seat belts over the past three decades, supplemented in recent years with the use of air bags. The authors focus on injuries caused by, rather than prevented by, these safety devices. Multiple studies confirm that seat belts, when compared with no restraints, have decreased fatalities by 43%-50% and serious injuries by 45%-55%. However, compliance with seat belts is still not close to 100%. The authors stress that while it is vital for the public to continue to be made aware of these reductions in injury and fatalities from restraint systems, the medical community and in particular, trauma physicians, need to have an increased awareness of the myriad of injuries that can be sustained from those same life-saving systems. They report the findings of their literature review, in five areas: mechanism of action of current restraint systems, individual organ injury patterns (air bag injuries), seat belt injuries, intestinal injury resulting from seat belts, and the diagnostic imaging of hollow viscus injuries. The authors conclude that intestinal injuries from automobile accidents are more common in restrained occupants and the seat belt mark should result in a heightened suspicion for intraabdominal injury to the physician caring for the injured occupant. The vast majority of air bag injuries are minor, but when air bags are used without a seat belt, the risk of cervical spinal cord injury is increased.

Management of Patients with Abdominal Malignancy after Remote Jejunoileal Bypass: Surgical Considerations Decades Later

Jejunoileal bypass (JIB) operations were introduced in 1963 as a surgical treatment for morbid obesity. The procedure gained popularity in the 1960s and 1970s as the most effective surgical intervention at the time for achieving and maintaining weight loss. However, both shortand long-term follow-up after these operations revealed a barrage of metabolic complications, including diarrhea, acute liver failure, cirrhosis, renal lithiasis, and renal insufficiency. Mortality and morbidity rates associated with the procedure were considerable and the procedure was eventually abandoned in favor of safer bariatric surgery alternatives. As a result, up to 33% of patients who had received a JIB underwent a reversal procedure. The most compelling reasons for reversal were lifethreatening malnutrition, immune complex disease, renal oxalate stones, osteomalacia, and severe electrolyte disturbance. A small group of patients underwent reversal secondary to the reduced quality of life caused by severe diarrhea and foul-smelling stools. Those patients that survived the procedure and metabolic sequelae were found to compensate for the profound malabsorption with hypertrophy of the minimally functional small bowel and profound hypertrophy of the entire colon. Four decades after the peak of these operations, this aging population is now presenting with surgical gastrointestinal diseases to a younger generation of surgeons who likely never performed these historical operations or managed their metabolic needs. Long-term follow-up of post-bariatric surgery patients, including those who underwent JIB, has revealed that the most common cause of death more than 12 months from the procedure is malignancy and not cardiovascular causes, as might have been suspected. Survivors are presenting with abdominal malignancies that our current generation of surgeons needs to manage. This article reviews preclinical and clinical data of the preoperative, operative, and postoperative considerations necessary to ideally manage these patients with a bowel resection.

Extrahepatic Biliary Tract and Gallbladder

This chapter discusses the embryologic origin and anatomy of the biliary structures. Explanations regarding biliary anatomy as it pertains to cholecystectomy are provided. The physiology of the biliary tree is discussed, as it applies to the clinical presentation of biliary disease and surgical findings. The general principles of biliary reconstruction and the management of biliary cancer are covered.

Thoracic Wall and Pleura

The focus of this chapter is the segmental anatomy of the chest wall, and the organization of the bony, muscular, and neurovascular elements that are important to understand when performing procedures including tube thoracostomy and intercostal anesthetic blocks. Also explored is the mechanisms of traumatic chest injury and the overall organization of mediastinal elements.

Malignant masquerade of xanthogranulomatous cholecystitis on intraoperative ultrasound of the liver.

introduces gallbladder carcinoma into the differential diagnosis—a rare disease best managed by an experienced oncologic surgeon. A 68-year-old Japanese gentleman presented with weight loss, anorexia, and abdominal discomfort. He had been on chronic opioid use for the last decade for back pain secondary to degenerative joint disease. His pain was not associated with meals, time of day, or any identifiable inciting factors. CT scan of the abdomen revealed a large stone in the neck of the gallbladder (small arrow) with marked irregularity along the superior portion of the organ suggesting a neoplasm (large arrow, panel A). A transabdominal ultrasound revealed a 3 cm echogenic stone in the lumen, a thickened gallbladder wall measuring up to 1.2 cm in maximum diameter, and focal irregular thickening of the wall adjacent to the liver read by the radiologist to be consistent with neoplasm. White blood cell count, liver function tests, CEA, and Ca19-9 were within normal limits. The patient was

Staying Alive: Strategies for Accountable Health Care

The Patient Protection and Affordable Care Act signed into law in March 2010, has led to sweeping changes to the US health care system. The ensuing pace of change in health care regulation is unparalleled and difficult for physicians to keep up with. Because of the extraordinary challenges that have arisen, the public policy committee of the Society for Surgery of the Alimentary tract conducted a symposium at their 52nd Annual Meeting in May 2011 to educate participants on the myriad of public policy changes occurring in order to best prepare them for their future. Expert speakers presented their views on policy changes affecting diverse areas including patient safety, patient experience, hospital and provider fiscal challenges, and the life of the practicing surgeon. In all areas, surgical leadership was felt to be critical to successfully navigate the new health care landscape as surgeons have a long history of providing safe, high quality, low cost care. The recognition of shared values among the diverse constituents affected by health care policy changes will best prepare surgeons to control their own destiny and successfully manage new challenges as they emerge.

Techniques to perform robotic left adrenalectomy in the obese patient

IntroductionMinimally invasive adrenalectomy may be associated with reduction in postoperative pain, morbidity, and length of stay and, as a result, has become a preferred approach for many adrenal tumors. Left-sided adrenal tumors, however, are particularly challenging to address in the morbidly obese patient due to difficulties in maintaining exposure and dissection. The robotic platform offers instruments with greater degrees of freedom that aid in retraction and dissection, especially of the adrenal vein, but fixed patient positioning and the large distance needed between patient ports to avoid arm collisions can be restrictive in patients with a large amount of retroperitoneal fat and small working space.Methods/ResultsWe demonstrate robotic left adrenalectomy (RLA) in a consecutive series of patients with a mean weight of 99 kg and mean BMI of 36. Techniques to safely and efficiently perform RLA in obese patients are stepwise demonstrated, including (1) Patient positioning, (2) Management of the pannus, (3) Customized port placement, (4) Medial retraction of the pancreas, (5) Finding the left adrenal vein, and (6) Management of bleeding. Intraoperative videos from multiple patients also show surgical pitfalls, examples of poor port placement, arm collisions, alternative approaches to the vein, and techniques to control unexpected bleeding. All patients in the series underwent successful RLA with negative margins, no major intra- or postoperative complications, and discharge on POD 1–2.ConclusionThough poor exposure due to patient body habitus is a relative contraindication, even large left-sided adrenal tumors can be safely approached robotically while adhering to oncologic principles, as is demonstrated in this video.

Hepatectomy After Yttrium-90 (Y90) Radioembolization-Induced Liver Fibrosis

An obese 55-year-old woman with nonalcoholic fatty liver disease presented 7 years after resection of a T3N1 ileal carcinoid tumor with an elevated chromogranin A, multifocal metastatic disease to the liver, and carcinoid syndrome. She underwent right hepatic artery yttrium-90 (Y90) radioembolization, followed a month later by selective Y90 treatment to segment IV. She then presented to our clinic 10 months later, remaining symptomatic with flushing, diarrhea, anxiety, myalgia, pain, and persistent night sweats despite Sandostatin administration. At least 11 tumors were identified in the right lobe of the liver and three in segment IV on liver-specific imaging. These lesions were stable over a year with no new lesions. At exploration, there was marked hypertrophy of the left lateral segment due to the yttrium-90 treatment of segments IV–VIII, corresponding with preoperative volumetrics predicting a functional liver remnant (FLR) of 40 % after extended right hepatectomy. The right lobe and segment IV were fibrotic, hard, and visibly damaged. The gland had a thick, fibrotic capsule, and the parenchyma was dense, inflexible, and difficult to dissect, consistent with the previously reported morbidity of these operations. Extended right hepatectomy was performed. Final pathology demonstrated 15 foci of metastatic well-differentiated neuroendocrine carcinoma that were negative for necrosis, as was expected given her continued symptoms despite radioembolization. Numerous amorphous spheres, frequently in clusters, were present in segments IV–VIII in vessels and approximating tumors consistent with prior Y90 radioembolization. The patient had an uneventful post-operative recovery and remains symptom free on follow-up. Treatment options for metastatic tumors to the liver have increased in recent years and currently include radioembolization in selected patients. Surgical cytoreduction and complete metastasectomy continue to offer improvement in symptoms, quality of life, and survival in patients with neuroendocrine liver metastases; however, hepatectomy after radioembolization is unique and carries increased morbidity/mortality, likely due to Y90-induced liver fibrosis. We demonstrate images of fibrotic yttrium-90 radiation-affected liver and histological sections of radioembolic microbeads in blood vessels and distributed around resected tumors.