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In recent years, as the high burden of surgical disease and poor access to surgical care in low- and middle-income countries have gained recognition as major public health problems, interest in global health has surged among surgical trainees and faculty. Traditionally, clinical volunteerism was at the forefront of the high-income country response to the significant burden of surgical disease in low- and middle-income countries. However, sustainable strategies for providing surgical care in low- and middle-income countries increasingly depend on bilateral clinical, research, and education collaborations to ensure effective resource allocation and contextual relevance. Academic global surgery creates avenues for interested surgeons to combine scholarship and education with their clinical global surgery passions through incorporation of basic/translational, education, clinical outcomes, or health services research with global surgery. Training in global health, either within residency or through advanced degrees, can provide the necessary skills to develop and sustain such initiatives. We further propose that creating cross-continental, bidirectional collaborations can maximize funding opportunities. Academic institutions are uniquely positioned to lead longitudinal and, importantly, sustainable global surgery efforts. However, for the individual global surgeon, the career path forward may be unclear. This paper reviews the development of academic global surgery, delineates the framework and factors critical to training global surgeons, and proposes models for establishing an academic career in this field. Overall, with determination, the academic global surgeon will not only carve out a niche of expertise but will define this critical field for future generations.

Global surgery is an emerging academic discipline that is developing in tandem with numerous policy and advocacy initiatives. In this regard, academic global surgery will be crucial for measuring the progress toward improving surgical care worldwide. However, as a nascent academic discipline, there must be rigorous standards for the quality of work that emerges from this field. In this white paper, which reflects the opinion of the Global Academic Surgery Committee of the Society for University Surgeons, we discuss the importance of research in global surgery, the methodologies that can be used in such research, and the challenges and benefits associated with carrying out this research. In each of these topics, we draw on existing examples from the literature to demonstrate our points. We conclude with a call for continued, high-quality research that will strengthen the discipline's academic standing and help us move toward improved access to and quality of surgical care worldwide.

Surgeons are traditionally categorized as working either in academic or private/community practice, but some transition between the two environments. Here, we profile current academic cardiothoracic surgeons who began their attending careers in private or community practice. We hypothesized that research activity may distinguish cardiothoracic surgeons who started in non-academic versus academic practice.Publicly available data regarding professional history and research productivity were collected for 992 academic cardiothoracic surgeons on faculty at the 77 cardiothoracic surgery training programs in the United States in 2018. Data are presented as medians analyzed with the Mann-Whitney test or proportions analyzed with Fisher exact test or the χA total of 80 (8.1%) academic cardiothoracic surgery faculty started their careers in non-academic practice, and 912 (91.9%) started directly in academia. Those who started in non-academic practice spent a median 7.0 y in private/community practice and were more likely to be cardiac surgeons (68.8% vs 51.6%, P = .0132). They were equally likely to pursue a protected research fellowship (56.3% vs 57.0%, P = .9067) and publish research during training (92.5% vs 91.1%, P = .8374), but they published fewer total papers by the end of cardiothoracic surgery fellowship (3.0 vs 7.0, P = .0001) and fewer papers per year as an academic attending (0.8 vs 2.9, P.0001). Nevertheless, the majority of cardiothoracic surgery faculty who started in non-academic practice are currently active in research (68.8%), and 2 such surgeons received National Institutes of Health R01 funding.Transitioning from non-academic to academic practice is an uncommon but feasible pathway for interested cardiothoracic surgeons.

The risk of port-site metastasis after laparoscopic removal of incidental gallbladder cancer was previously estimated to be 14-30%. The present study was designed to determine the incidence of port-site metastasis in incidental gallbladder cancer in the modern era (2000-2014) versus the historic era (1991-1999). We also investigated the site of port-site metastasis.Using PRISMA, a systematic review was conducted to identify papers that addressed the development of port-site metastasis after laparoscopic resection of incidental gallbladder cancer. Studies that described cancer-specific outcomes in ≥5 patients were included. A validated quality appraisal tool was used, and a weighted estimate of the incidence of port-site metastasis was calculated.Based on data extracted from 27 papers that met inclusion criteria, the incidence of port-site metastasis in incidental gallbladder cancer has decreased from 18.6% prior to 2000 (95% confidence interval 15.3-21.9%, n = 7) to 10.3% since then (95% confidence interval 7.9-12.7%, n = 20) (P .001). The extraction site is at significantly higher risk than nonextraction sites.The incidence of port-site metastasis in incidental gallbladder cancer has decreased but remains high relative to other primary tumors. Any preoperative finding that raises the suspicion of gallbladder cancer should prompt further investigation and referral to a hepato-pancreato-biliary specialist.

Surveys are important research tools that permit the accumulation of information from large samples that would otherwise be impractical to collect. Resident surveys have been used frequently to monitor the quality of postgraduate training. Low response rates threaten the utility of this research tool. The purpose of this study was to determine the standard response rate of surveys administered to surgery residents and identify characteristics associated with achieving greater response rates.A search of peer-reviewed literature published between September 2003 and June 2011 was performed with the use of PubMed with Medical Subject Headings: "internship and residency," "surgery," "data collection," and "questionnaires." For inclusion, articles must have described a survey given to active surgery residents within the United States. Surveys were evaluated based on the following criteria: population size, response rate, incentive use, follow-up use, survey format (online vs paper), and institution versus national.Of 433 initial results, 47 met inclusion criteria with a mean response rate of 65.3%. Surveys administered in paper format had a greater response rate compared with those given electronically (mean 78.6% vs 36.4%, respectively, P.001). Greatest mean response rates were seen for institutional surveys compared with those given nationally (83.1% vs 42% respectively, P.001).Our review demonstrated that paper surveys administered at the institutional level and during assemblies integrated into residents' schedules demonstrated enhanced response rates. The validity and generalizability of data collected through such surveys will improve as the aspects which dictate response rate are better understood and implemented.

Background A prior study revealed a paucity of surgical research in the 5 top-rated general surgery journals for 1998. The hypothesis of the current study was that a large amount of surgical research was published in other journals. Methods In all, 15 research journals and 9 surgery specialty journals were reviewed for basic research, funded clinical studies, randomized clinical trials, and drug trials. The funding sources and the surgeon's role were recorded. The findings were compared with research published in the previously studied 5 journals in 1998 and 2005. Results Of 6,016 papers in the research and surgery specialty journals, 19% were research, of which 76% were basic research. Funding from 1,101 sources was provided to 825 studies (70%). Seventy-four percent of funded studies were basic research. Government was the source for 46% of grants, private for 41%, and industry for 13%. A surgeon was the sole or senior author in 72% of studies. A total of 1,172 research articles were published in the research and surgery specialty journals in 1998. In comparison, 369 research papers were published in the general surgery journals in 1998 and 306 papers were published in 2005. With respect to the type of research, there were 896 basic research papers in the research and specialty journals in 1998, 200 such papers in the general surgery journals in 1998, and 164 in 2005. There were 87 randomized trials in the research and the surgery specialty journals in 1998, 46 such papers in the general surgery journals in 1998, and 29 in 2005. Conclusion A 3-fold greater volume of surgical research and more than a 4-fold greater volume of basic research was found in the research and the surgical specialty journals than in the general surgical journals in 1998, and this margin is increased when compared with the data for 2005. Consideration of only the general surgical journals greatly underestimates the surgical research being conducted.

This study was performed to identify factors that impact student performance on a web-based objective structured clinical evaluation (OSCE) that was developed to improve the evaluation process of students who complete a fourth-year surgical clerkship in trauma-critical care.We created a multiple-choice OSCE with commercially available software. Clinical cases were developed for incorporation into 7 quizzes that were assembled to appear as 1 examination. Students used intensive care unit flow sheets to review data, to develop a systems-based problem list and differential diagnoses, and to produce treatment recommendations.No difference was noted in a comparison of the mean scores that were achieved by students on a previous paper (essay format) OSCE and the new web OSCE. There was a correlation of student performance on the web OSCE to the National Board of Medical Examiners (NBME) subject examination that had been completed the previous year (r = 0.60; P.0001). Performance on the NBME subject examination was the only independent factor that affected reporter, interpreter, and manager skills that were assessed by the OSCE (P.01).Implementation of a web OSCE resulted in similar performance of the class as compared with performance on the previous paper OSCE. Correlation of student achievement on the web OSCE to the NBME subject examination supported the construct validity of this institutional examination beyond the areas of face and content validity in which OSCEs may excel.

Background The Surgeon General oversees the Commissioned Corps of the U.S. Public Health Service (USPHS) and is viewed as the “Nation’s Doctor,” responsible for providing the public with information on living healthier and safer lives. The Surgeon General’s influence is seen through public health initiatives such as warning labels on tobacco and alcohol products. The objectives of this paper are to describe the tradition of the Office of the Surgeon General as created by Dr John M. Woodworth and to describe the careers of Dr C. Everett Koop and Dr Richard H. Carmona—the only 2 surgeons by training to hold the role. Methods This is a historical literature review using a combination of primary and secondary sources. Results Dr Woodworth set the priorities and responsibilities of the Surgeon General’s Office: education, public service, sanitation, and public health. Dr Koop is widely regarded as the most influential Surgeon General of all time. He was both a pioneer in pediatric surgery and a highly influential public figure, issuing landmark reports on smoking, violence, and AIDS. Dr Carmona is a trauma surgeon by training and focused on the dangers of second-hand smoke as Surgeon General. Dr Carmona served in a more political role as Surgeon General, eventually running for Senate at the end of his term. Conclusion This brief review of the history of the Surgeon General’s Office highlights the contributions of the first Surgeon General and the only 2 surgeons who have held the position.

Background Subtotal cholecystectomy is recognized as a rescue procedure performed in grossly suboptimal circumstances that would deem a total cholecystectomy too risky to execute. An earlier systematic review based on 30 studies published between 1985 and 2013 concluded that subtotal cholecystectomy had a morbidity rate comparable to that of total cholecystectomy. This systematic review appraises 17 clinical outcomes in patients undergoing subtotal cholecystectomy. Methods The study protocol was registered with the International Prospective Register for Systematic Reviews (CRD42020172808). MEDLINE, Embase, Cochrane bibliographic databases, and Google Scholar were used to identify papers published between 1985 and June 2020. Data related to the surgical setting, approach, intervention on the hepatic wall of the gallbladder, type of completion of subtotal cholecystectomy, year of study, and study design were collected. Seventeen clinical outcomes were considered. Meta-analyses were performed using a random-effects model, and the effect size was presented as risk ratios with 95% confidence intervals. Results From 1,017 records, 85 eligible studies were identified and included. These included 3,645 patients who underwent subtotal cholecystectomy. Laparoscopic (80.1%, n = 2,918) and reconstituting (74.6%, n = 2,719) approaches represented the majority of all subtotal cholecystectomy cases. Seven (0.2%) cases of injury to the bile duct were reported. Bile leak was reported in 506 (13.9%) patients. Reconstituting subtotal cholecystectomy was associated with a lower risk for 11 clinical outcomes. Open subtotal cholecystectomy was associated with an increased rate of 30-day mortality and wound infections. Conclusion Subtotal cholecystectomy is associated with significant morbidity. Laparoscopic and reconstituting surgery may reduce the risks of some perioperative complications and long-term sequelae after subtotal cholecystectomy.

Background A minimally invasive step-up approach to necrotizing biliary pancreatitis often requires multiple interventions, delaying cholecystectomy. The risk of gallstone-related complications during this time interval is unknown, as is the feasibility and safety of cholecystectomy after minimally invasive step-up treatment. In this paper, we analyzed both. Methods Necrotizing pancreatitis patients treated with a minimally invasive step-up approach who underwent interval cholecystectomy at 2 tertiary care centers between 2014 and 2019 were included. Gallstone-related complications prior to cholecystectomy were examined, as were surgical approaches to cholecystectomy and complications. Necrotizing pancreatitis patients treated without mechanical intervention were also examined. Results Seven of 31 patients developed gallstone-related complications between minimally invasive step-up treatment initiation and cholecystectomy. One patient developed biliary colic. Six patients developed acute cholecystitis. Two of these patients also developed choledocholithiasis, and 1 developed cholangitis, all requiring endoscopic retrograde cholangiopancreatography. Cholecystectomy was performed laparoscopically in 27 of 31 patients. One patient required open conversion, and 3 patients underwent planned cholecystectomy during another open operation. Four patients developed postoperative complications. Two of 14 necrotizing pancreatitis patients treated without mechanical intervention developed recurrent pancreatitis while awaiting cholecystectomy. Conclusion Over 20% of necrotizing pancreatitis patients treated by a minimally invasive step-up approach developed gallstone-related complications while awaiting cholecystectomy. Laparoscopic cholecystectomy is feasible and safe in the great majority of necrotizing pancreatitis patients treated by a minimally invasive step-up approach.

Background The objectives of this paper are to describe the shortcomings of current techniques for treatment of preauricular sinus (PAS) and to introduce a new surgical technique. PAS is a common congenital abnormality. Usually these lesions are asymptomatic. However, some patients complain of discharge and/or (recurrent) infections, and require excision. Surgical treatment of PAS is characterized by high recurrence rates. This paper describes a single institution's experience with the operative management of PAS and introduces a new technique. Methods Data on PAS procedures were collected from a retrospective review of patients' charts and interviews by questionnaire of all patients treated operatively for PAS in the Leiden University Medical Centre from 1984 to 2003. Results Thirty-nine patients (21 male, 18 female) with PAS underwent 40 procedures for PAS. These procedures included 17 classic operations (in 16 patients) and the “inside-out technique” in 23 patients. In the patient group treated “classically,” 2 patients developed a recurrence; one underwent successful reoperation; the other patient has been lost to follow-up. Another patient developed wound breakdown postoperatively, resulting in an ugly scar. Two patients had postoperative infections requiring treatment. Neither recurrences nor complications requiring treatment occurred in the group who underwent the inside-out technique. Conclusions The inside-out technique provides an easy solution for patients with PAS. However, further study on a larger patient group is necessary.

Background Pancreatic neuroendocrine neoplasms are a heterogenous group of rare tumors whose natural history remains poorly defined. Accurate prognostication of pancreatic neuroendocrine neoplasms is essential for guiding clinical decisions. This paper aims to summarize all the commonly utilized and recently proposed prognostication systems for pancreatic neuroendocrine neoplasms published in the literature to date. Methods A systematic review of Pubmed, Scopus, and Embase databases, of the period from January 1, 2000–November 29, 2016, was conducted to identify all published articles reporting on prognostication systems of pancreatic neuroendocrine neoplasms. Results A total of 23 articles were included in our review, and a total of 25 classification systems were identified. There were 2 modifications of the World Health Organization 2004 criteria, 4 modifications of the World Health Organization 2010 criteria, 2 modifications of the American Joint Committee on Cancer 2010 staging system, 3 modifications of the European Neuroendocrine Tumor Society 2006 tumor, node, metastasis staging system, 7 novel categorial classification systems, and 2 novel proposed continuous classifications. The most commonly included variables included age, size of tumor, presence of distant and lymph node metastases, Ki-67 index, and mitotic count. Conclusion Numerous prognostication systems have been proposed for pancreatic neuroendocrine neoplasms, of which the most commonly used systems presently include the World Health Organization 2010 criteria and the two tumor, node, metastasis staging systems by the European Neuroendocrine Tumor Society and the American Joint Commission on Cancer. However, prognostication systems for pancreatic neuroendocrine neoplasms continue to evolve with time as more prognostication factors are identified. More validation and comparative studies are needed to identify the most effective prognostication system.

Portal venous system thrombosis can develop after bariatric surgery. A systematic review and meta-analysis was conducted to evaluate the incidence of portal venous system thrombosis after bariatric surgery and clarify the role of anticoagulation for the prevention of portal venous system thrombosis after bariatric surgery.PubMed, EMBASE, and Cochrane Library databases were searched. The incidence of portal venous system thrombosis after bariatric surgery was pooled by a random-effect model. Subgroup analyses were performed to explore the incidence of portal venous system thrombosis according to the average duration of prophylactic anticoagulation (extended versus short-term). Meta-regression and sensitivity analyses were performed to explore the source of heterogeneity.Among 2,714 papers initially screened, 68 studies were included. Among 100,964 patients undergoing bariatric surgery, 300 developed portal venous system thrombosis. The pooled overall incidence of portal venous system thrombosis after bariatric surgery was 0.419% (95% confidence interval: 0.341%-0.505%). The pooled incidence of portal venous system thrombosis after bariatric surgery was numerically lower in patients who received extended prophylactic anticoagulation protocol after bariatric surgery than those who received short-term prophylactic anticoagulation protocol (0.184% vs 0.459%). Meta-regression analyses demonstrated that sample size (P = .006), type of surgery (P.001), and average duration of prophylactic anticoagulation (P = .024) might be sources of heterogeneity, but not region, publication year, history of bariatric surgery, follow-up duration, or use of prophylactic anticoagulation. Sensitivity analyses could not identify any source of heterogeneity. The estimated mortality of portal venous system thrombosis after bariatric surgery was 1.33%.Portal venous system thrombosis after bariatric surgery is rare, but potentially lethal. Extended prophylactic anticoagulation protocol may be considered in patients at a high risk of developing portal venous system thrombosis after bariatric surgery.

Objective We aimed to investigate clinical symptom and epidemiological features of ESP-infected COVID-19 Summary Background Data Almost one million of 2019 novel coronavirus disease (COVID-19) patients were diagnosed in the world wide from December 2019 to now. Thousands of emergency operations were carried out in the interim. However no one focused on the clinical symptom of emergency surgery patients (ESP) with COVID-19 pneumonia. Methods Retrospective cohort study of 164 ESP with or without COVID-19 pneumonia in Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 20, 2020. The final date of follow-up was February 5, 2020. The associated clinical, laboratory, epidemiological, demographic, radiological and outcome data were collected and analyzed. Results Of 164 ESP, the median age was 41 years old (interquartile range (IQR), 29-89) and 136 (82.9%) were women. Associated main clinical symptom including fever (93 [56.7%]), dry cough (56 [34.2%]), fatigue (86 [52.4%]), nausea (78 [47.6%]) and dizziness (77 [47%]). Of 54 ESP-infected COVID-19 patients, the median age was 46 (IQR: 25-89) and 45 (83.3%) were women. The pathological clinical symptoms including fever (54 [100%]), fatigue (48 [88.9%]), nausea (52 [96.3%]), dizziness (46 [85.2%]) and dry cough (44 [81.5%]) were investigated; the lymphopenia (0.37×109/L [IQR: 0.23-0.65]) and increased C-reactive protein (24.7×109/L [IQR: 13.57-38]) were observed. The preoperative fever and postoperative fever in ESP with or without COVID-19 pneumonia were analyzed in this study. Of 54 ESP with COVID-19 patients, 15 (27.8%) patients showed preoperative fever, 54 (100%) had the postoperative fever; Of 110 non-COVID-19 of ESP, 5 (4.5%) patients had preoperative fever, 31 (28.2%) patients had the postoperative fever. The fever in ESP with COVID-19 lasted more than 7 days, markedly exceeded the non-COVID-19 patients (lasted about 3 days). Furthermore, 43 health care workers were infected from exposed to ESP with COVID-19 pneumonia. Conclusion In our study, the clinical symptoms of ESP-infected COVID-19 displayed marked differences from those reported common COVID-19 pneumonia cases. Additionally, the health care workers were confirmed to expose great risk in ESP with COVID-19 pneumonia. Management guidelines of ESP were described in our paper., Highlights TOC Statement- 20200643 In our study, the clinical symptoms of ESP-infected COVID-19 displayed marked differences from those reported common COVID-19 pneumonia cases and the health care workers were confirmed to expose great risk in ESP with COVID-19 pneumonia. The importance of this findings is these will provide early warning for health care workers who take care of the ESP-infected COVID-19 patients on now and in the future.

LAST YEAR, SURGERY PUBLISHED a study by Schein and Paladugu1 documenting the incidence of dual publication and “salami slicing” in 3 surgical journals (Surgery, British Journal of Surgery, and Archives of Surgery) in the calendar year 1998. The editors of Surgery reviewed (and confirmed) all the articles claimed to be dual publications: there were a frightening number of true dual publications that represented 3% of all articles in those 3 journals that year—indicative of a form of academic dishonesty. This and similar transgressions led the editors of 23 surgical journals to publish a joint statement in June 2001 in each of their journals2 setting forth criteria to be followed by authors submitting their work to these journals. Recently, Surgery was asked to retract a previously published paper. Serious concerns were raised regarding the content, data analysis, and the authorship of the work. Because of the doubts raised about the data and the process of submission, we are publishing a retraction of this paper in this issue. The central issue here is academic dishonesty. Numerous attestations concerning authorship, scientific validity, financial disclosure, ownership of copyright, etc, are built into our system of manuscript submission. Ultimately we must rely on the honesty of the submitting authors and the veracity of the data. Situations involving dual publication and allegations of academic dishonesty are disheartening and distasteful. What must we learn from this? Any submission for publication must first be reviewed, read, and approved by all authors before submission. Perhaps subsequent communications from Surgery should be shared with all authors; in any event, all authors must again approve the revised manuscript and resubmission cover letter. Submission and publication bestows a responsibility on all involved—the authors, the institution, Surgery, and the scientific community. This is serious business— we all work too hard to achieve credibility to allow ourselves to fall prey to charges of academic fraud.

Few details are known about open-access surgery journals that solicit manuscripts via E-mail. The objectives of this cross-sectional study are to compare solicitant surgery journals with established journals and to characterize the academic credentials and reasons for publication of their authorship.We identified publishers who contacted the senior author and compared their surgery journals with 10 top-tier surgical journals and open-access medical journals. We assessed the senior authorship of articles published January 2017-March 2017 and utilized a blinded survey to determine motivations for publication.Throughout a 6-week period, 110 E-mails were received from 29 publishers distributing 113 surgery journals. Compared with established journals, these journals offered lesser publication fees, but also had lesser PubMed indexing rates and impact factors (all P.002). Professors, division chiefs, and department chairs were the senior authors of nearly half of US-published papers and spent ≈$83,000 to publish 117 articles in journals with a median impact factor of 0.12 and a 33% PubMed indexing rate. Survey responses revealed a dichotomy as 43% and 57% of authors published in these journals with and without knowledge of their solicitant nature, respectively. The most commonly reported reasons for submission included waived publication fees (50%), invitation (38%), and difficulty publishing elsewhere (12%).Despite their sparse PubMed indexing and low impact factors, many senior academic faculty publish in solicitant surgery journals. This study highlights the importance for the academic surgical community to be cognizant of the quality of a journal when reviewing the literature for research and evidence-based practice.

Simulation has become an integral part of physician education, and abundant evidence confirms that simulation-based education improves learners' skills and behaviors and is associated with improved patient outcomes. The resources required to implement simulation-based education, however, have led some stakeholders to question the overall value proposition of simulation-based education. This paper summarizes the information from a special panel on this topic and defines research priorities for the field. Future work should focus on both outcomes and costs, with robust measurement of resource investments, provider performance (in both simulation and real settings), patient outcomes, and impact on the health care organization. Increased attention to training practicing clinicians and health care teams is also essential. Clarifying the value proposition of simulation-based education will require a major national effort with funding from multiple sponsors and active engagement of a variety of stakeholders.

Many Arab countries have undergone the epidemiologic transition of diseases with increasing economic development and a proportionately decreasing prevalence of communicable diseases. With this transition, injuries have emerged as a major cause of mortality and morbidity in the Gulf Cooperation Council countries in addition to diseases of affluence. Injuries are the number one cause of years of life lost and disability-adjusted life-years in the Sultanate of Oman. The burden of injuries, which affects mostly young Omani males, has a unique geographic distribution that is in contrast to the trauma care capabilities of the country. The concentration of health care resources in the northern part of the country makes it difficult for the majority of Omanis who live elsewhere to access high-quality and time-sensitive care. A broader multisectorial national injury prevention strategy should be evidence based and must strengthen human resources, service delivery, and information systems to improve care of the injured and loss of life. This paper provides a unique overview of the Omani health system with the goal of examining its trauma care capabilities and injury control policies.

Owing to increasing external pressures on both faculty and learners, the practice of bedside teaching is declining. The objective of this paper is to provide an overview of educational strategies to foster bedside teaching in the current clinical practice environment for surgical educators. General strategies include building a culture within the program that promotes the atmosphere of a learning community, and providing scaffolding for trainees that fosters gradual progression to autonomous practice. Specific techniques for bedside teaching include CAMEO, the "one-minute preceptor", and mini-presentations or peer-teaching. The intentional and proactive implementation of these strategies alongside others can assist educators in capturing the "redeemable moments" that occur in the course of routine clinical care at the patient's bedside.

Background Handover of patient care is a critical process in the transfer of information between clinical teams and clinicians during transitions in patient care. The handover process may take many forms and is often unstructured and unstandardized, potentially resulting in error and the potential for patient harm. The Joint Commission has implicated such errors in up to 80% of sentinel events and has published guidelines (using an acronym termed SHARE) for the development of intervention tools for handover. This study aims to review interventions to improve handovers in surgery and to assess compliance of described methodologies with the guidelines of the Joint Commission for design and implementation of handover improvement tools. Methods A systematic review was conducted in line with MOOSE guidelines. Electronic databases Medline, EMBASE, and PsyInfo were searched and interventions to improve surgical handover identified. Intervention types, development methods, and outcomes were compared between studies and assessed against SHARE criteria. Results Nineteen studies were included. These studies included paper and computerized checklists, proformas, and/or standardized operating protocols for handover. All reported some degree of improvement in handover. Description of development methods, staff training, and follow-up outcome data was poor. Only a single study was able to demonstrate compliance with all 5 domains guidelines of the of Joint Commission. Conclusion Improvements in information transfer may be achieved through checklist- or proforma-based interventions in surgical handover. Although initial data appear promising, future research must be backed by robust study design, relevant outcomes, and clinical implementation strategies to identify the most effective means to improve information transfer and optimize patient outcomes.

Background This study assessed the extent to which individuals with surgically operable cancer in Southeast Asia experience financially catastrophic out-of-pocket costs, discontinuation of treatment, or death. Methods The ACTION study is a prospective, 8-country, cohort study of adult patients recruited consecutively with an initial diagnosis of cancer from public and private hospitals. Participants were interviewed at baseline and 3 months. In this paper, we identified 4,584 participants in whom surgery was indicated in initial treatment plans and assessed the following competing outcomes: death, financial catastrophe (out-of-pocket costs of >30% of annual household income), treatment discontinuation, and hospitalization without financial catastrophe incurred. We then analyzed a range of predictors using a multinomial regression model. Results Of the participants, 72% were female and 44% had health insurance at baseline. At 3 months, 31% of participants incurred financial catastrophe, 8% had died, 23% had discontinued treatment, and 38% were hospitalized but avoided financial catastrophe. Health insurance status was found to be associated with lower odds of treatment discontinuation (odds ratio [OR], 0.60; 95% CI, 0.47-0.77) relative to hospitalization without financial catastrophe. Women had greater odds of financial catastrophe than men (OR, 1.35; 95% CI, 1.05-1.74), whereas lower socioeconomic status (range of indicators) was generally found to be associated with higher odds of death, treatment discontinuation, and financial catastrophe. Conclusion Priority should be given to measures such as programs to extend social health insurance to offset the out-of-pocket costs associated with surgery for cancer faced in particular by women, the uninsured, and individuals of low socioeconomic status in Southeast Asia.

Although the Revitalization Act was passed in 1993 to increase enrollment of women in clinical trials, there has been little focus on sex disparity in basic and translational research. We hypothesize that sex bias exists in surgical biomedical research.Manuscripts from Annals of Surgery, American Journal of Surgery, JAMA Surgery, Journal of Surgical Research, and Surgery from 2011 to 2012 were reviewed. Data abstracted included study type, sex of the animal or cell studied, location, and presence of sex-based reporting of data.Of 2,347 articles reviewed, 618 included animals and/or cells. For animal research, 22% of the publications did not specify the sex of the animals. Of the reports that did specify the sex, 80% of publications included only males, 17% only females, and 3% both sexes. A greater disparity existed in the number of animals studied: 16,152 (84%) male and 3,173 (16%) female (P .0001). For cell research, 76% of the publications did not specify the sex. Of the papers that did specify the sex, 71% of publications included only males, 21% only females, and 7% both sexes. Only 7 (1%) studies reported sex-based results. For publications on female-prevalent diseases, 44% did not report the sex studied. Of those reports that specified the sex, only 12% studied female animals. More international than national (ie, United States) publications studied only males (85% vs 71%, P = .004), whereas more national publications did not specify the sex (47% vs 20%, P .0001). A subanalysis of a single journal showed that across three decades, the number of male-only studies and usage of male animals has become more disparate over time.Sex bias, be it overt, inadvertent, situational, financial, or ignorant, exists in surgical biomedical research. Because biomedical research serves as the foundation for subsequent clinical research and medical decision-making, it is imperative that this disparity be addressed because conclusions derived from such studies may be specific to only one sex.

Background We systematically reviewed the literature concerning simulation-based teaching and assessment of the Accreditation Council for Graduate Medical Education professionalism competencies to elucidate best practices and facilitate further research. Methods A systematic review of English literature for “professionalism” and “simulation(s)” yielded 697 abstracts. Two independent raters chose abstracts that (1) focused on graduate medical education, (2) described the simulation method, and (3) used simulation to train or assess professionalism. Fifty abstracts met the criteria, and seven were excluded for lack of relevant information. The raters, 6 professionals with medical education, simulation, and clinical experience, discussed 5 of these articles as a group; they calibrated coding and applied further refinements, resulting in a final, iteratively developed evaluation form. The raters then divided into 2 teams to read and assess the remaining articles. Overall, 15 articles were eliminated, and 28 articles underwent final analysis. Results Papers addressed a heterogeneous range of professionalism content via multiple methods. Common specialties represented were surgery (46.4%), pediatrics (17.9%), and emergency medicine (14.3%). Sixteen articles (57%) referenced a professionalism framework; 14 (50%) incorporated an assessment tool; and 17 (60.7%) reported debriefing participants, though in limited detail. Twenty-three (82.1%) articles evaluated programs, mostly using subjective trainee reports. Conclusion Despite early innovation, reporting of simulation-based professionalism training and assessment is nonstandardized in methods and terminology and lacks the details required for replication. We offer minimum standards for reporting of future professionalism-focused simulation training and assessment as well as a basic framework for better mapping proper simulation methods to the targeted domain of professionalism.

MINIMALLY INVASIVE THYROIDECTOMY (MIT) is the result of the efforts of several surgeons to extrapolate the proven benefits of minimally invasive techniques in the abdomen, chest, blood vessels, and joints (less pain and morbidity, shorter hospitalization, and improved aesthetics) compared with the traditional technique of open thyroidectomy. In the last decade, there has been an explosion of papers describing different techniques of minimally invasive thyroidectomy. One common advantage of all these techniques is either a smaller scar in the neck or the complete absence of a scar in the neck, although other theoretic advantages have been reported. The goal of this review is to classify all existing MIT techniques and discuss the future of these approaches based on the current literature and personal experience.

Background Health care systems provide care to increasingly complex and elderly patients. Colorectal surgery is a prime example, with high volumes of major procedures, significant morbidity, prolonged hospital stays, and unplanned readmissions. This situation is exacerbated by an exponential rise in costs that threatens the stability of health care systems. Enhanced recovery pathways (ERP) have been proposed as a means to reduce morbidity and improve effectiveness of care. We have reviewed the evidence supporting the implementation of ERP in clinical practice. Methods Medline, Embase, and the Cochrane library were searched for randomized, controlled trials comparing ERP with traditional care in colorectal surgery. Systematic reviews and papers on ERP based on data published in major surgical and anesthesiology journals were critically reviewed by international contributors, experienced in the development and implementation of ERP. Results A random-effect Bayesian meta-analysis was performed, including 6 randomized, controlled trials totalizing 452 patients. For patients adhering to ERP, length of stay decreased by 2.5 days (95% credible interval [CrI] −3.92 to −1.11), whereas 30-day morbidity was halved (relative risk, 0.52; 95% CrI, 0.36–0.73) and readmission was not increased (relative risk, 0.59; 95% CrI, 0.14–1.43) when compared with patients undergoing traditional care. Conclusion Adherence to ERP achieves a reproducible improvement in the quality of care by enabling standardization of health care processes. Thus, while accelerating recovery and safely reducing hospital stay, ERPs optimize utilization of health care resources. ERPs can and should be routinely used in care after colorectal and other major gastrointestinal procedures.

Background Disconnected left pancreatic remnant (DLPR) presents clinically as a pancreatic fistula, pseudocyst, or obstructive pancreatitis. Optimal operative treatment, either distal pancreatectomy (DP) or internal drainage (ID), remains unknown. This paper critically evaluates our operative experience in patients with DLPR. Methods A retrospective analysis of a consecutive case series from a single, high-volume institution was carried out. A total of 76 patients with radiographic-confirmed DLPR (computed tomography + endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography) who had operations between November 1995 and September 2008 were included. Pancreas preservation (the use of ID) was our default unless anatomic, physiologic, or technical factors precluded it. Follow-up to July 2009 was done (median follow-up, 22 months). Standard statistical methodology was used (P Results The mean age of this cohort was 52 years (range, 18–85); 57% of the patients were male. A total of 59 (73%) had acute pancreatitis, whereas 17 (22%) had chronic pancreatitis. Presentation was pseudocyst in 53%, pancreatic fistula in 34%, and obstructive pancreatitis in 13%. Resection (DP) and drainage (ID) options were utilized equally for each clinical presentation as follows: pseudocyst, 60/40; pancreatic fistula, 50/50; or obstructive pancreatitis, 50/50. The strongest driver for DP (92%) was a small pancreatic remnant and splenic vein thrombosis. In contrast, large pancreatic remnants had ID 70% of the time. No differences in short- or long-term outcomes between DP or ID options were identified. Conclusion Using anatomic, physiologic, and technical factors to guide operative choice in DLPR, we report a 74% success rate with DP and an 82% success rate with ID at a median follow-up of 22 months. A pancreatic remnant size >6 cm favored ID options over resection.

The purpose of this study was to determine if there was an increase in the average number of articles published per year for surgery department chairs and if there was an association of publication patterns during their academic careers to authorship position and types and quality of articles written.Computerized literature searches were performed for 299 chairs of departments of surgery between 1950 and 2004. We compiled data on time as chair, number of publications per year, article types, authorship positions, and impact factors of the journals. Nonparametric tests allowed identification of differences between groups, and regression analyses were used to analyze publication trends over time.There was a significant increase in the number of articles published per year from the beginning to the end of the study (P.01). Articles were more likely to be clinical than nonclinical (P.01), and more review articles were written for nonclinical publications (P.01). Individuals overall were most likely to be last authors than first or contributing authors (P.01). More papers were published prior to becoming chairs compared to during tenure as chair or post-chair (P.01). As post-chairs, individuals were most likely to be contributing authors (P.01). There was no difference in the quality of the journals to which chairs' submitted their manuscripts during their academic careers.These findings provide valuable insight into the publication patterns of chairs of surgery departments. Individuals publish fewer articles as chairs and post-chairs, most likely due to the greater emphasis on administration and leadership duties during these career stages. Nevertheless, surgical department chairs tend to publish prolifically throughout their careers.

Background It is vital for clinicians to understand and interpret correctly medical statistics as used in clinical studies. In this review, we address current issues and focus on delivering a simple, yet comprehensive, explanation of common research methodology involving receiver operating characteristic (ROC) curves. ROC curves are used most commonly in medicine as a means of evaluating diagnostic tests. Methods Sample data from a plasma test for the diagnosis of colorectal cancer were used to generate a prediction model. These are actual, unpublished data that have been used to describe the calculation of sensitivity, specificity, positive predictive and negative predictive values, and accuracy. The ROC curves were generated to determine the accuracy of this plasma test. These curves are generated by plotting the sensitivity (true-positive rate) on the y axis and 1 - specificity (false-positive rate) on the x axis. Results Curves that approach closest to the coordinate (x = 0, y = 1) are more highly predictive, whereas ROC curves that lie close to the line of equality indicate that the result is no better than that obtained by chance. The optimum sensitivity and specificity can be determined from the graph as the point where the minimum distance line crosses the ROC curve. This point corresponds to the Youden index (J), a function of sensitivity and specificity used commonly to rate diagnostic tests. The area under the curve is used to quantify the overall ability of a test to discriminate between 2 outcomes. Conclusion By following these simple guidelines, interpretation of ROC curves will be less difficult and they can then be interpreted more reliably when writing, reviewing, or analyzing scientific papers.

This article has been retracted at the request of the Editors. Please see http://www.elsevier.com/locate/withdrawalpolicy . Reason: It has been called to our attention by one of the indentified authors, Dr. Minoru Uematsu of Keio University School of Medicine, that he did not contribute to this paper and was unaware of its submission. In addition, Dr. Uematsu informs us that the data appear to be an updated version without attribution to his presentation at the 22nd Annual San Antonio Breast Cancer Symposium December 8–11, 1999 (previously published as an abstract (Breast Cancer Research and Treatment 1999; 57:108). Dr. Uematsu also states that the information contained in the SURGERY article is misleading and inaccurate in that the patients were treated with whole breast irradiation in addition to the accelerated partial breast irradiation, a fact that was not stated in the article. The Editors feel that this is a serious misrepresentation of the treatment method. The Editors have contacted Kazuhiko Sato, M.D., Ph.D., who submitted the manuscript for publication and is its first author. Dr. Sato concedes and apologizes for (1) the listing of Dr. Uematsu as an author without his permission, (2) failing to provide the attribution to the original presentation and (3) omitting the crucial fact that conventional whole breast irradiation of 50 Gy was used as a further treatment of patients receiving the APBI. With these facts in hand, it is regrettable but necessary that we retract this article in its entirety.

THE WORD CURRICULUM has its origins in the running and chariot tracks of Greece. It was, literally, a course. 1 As time and society have evolved, educators’ views of the meaning of curriculum have changed. Varying philosophic positions on the role of education in society and disparate assumptions about what helps people learn shaped educators’ views about curriculum and how they defined it. The purpose of this paper is to describe two popular classifications of curriculum, briefly explain the educational theory associated with each, and review their implications for teachers and learners. The test of good theory is whether it can guide practice. In reverse, good practice is based on theory. A framework for thinking about curriculum theory and practice is important in light of current efforts to redesign curriculum for surgical residency education. Various taxonomies exist for categorizing curriculum theories, theorists, and models. 1 For the

Background The problem of safe and efficient transfer of care has increased over the years as new and complex diagnostic tools and more complex treatment options became available. Traditionally, residents ensured continuity of care by working long hours and minimizing the transfer of significant diagnostic or therapeutic responsibilities to other providers. The new 80-hour workweek has curtailed that practice and increased the pressure on trainees for workflow efficiency. We report on a study of information-handling routines among residents for the separate tasks of transfer of care (“sign-out”) and daily patient care work (ward work). Using these results, an institution-wide computerized system was developed to centralize information-handling tasks and facilitate the management and transfer of patient care information. Study design House staff from 31 resident-run inpatient and consult services at 2 teaching hospitals described current methods of maintaining patient information used during ward rounds and during sign-out. A subgroup of 28 residents then participated in the design of a computerized resident sign-out system to centralize patient information and produce lists for rounding and transferring care duties. Accuracy, flexibility, and portability were identified as key elements by the design team. Results Analysis of the type of information handled by residents caring for inpatients at our institution demonstrated common elements across many services. Most services used a paper patient list to manage both nightly sign-out and daily ward work, which required repeated recopying of patient data during the day. Utilizing medical information systems tools and rapid application development concepts, we constructed a computerized resident sign-out system (“UWCores”). This system combines the patient sign-out and daily ward work information in one central location. We believed this would improve the quality of information transferred during sign-out and enhance resident efficiency. During the design process, we identified rules that govern the type of clinical information that should be automatically versus manually updated. We observed an immediate acceptance by all residents and services that tried the system. Conclusions This study shows that by combining downloaded patient data from hospital systems with resident-entered patient details, a computerized resident sign-out system can be a feasible, powerful, and popular tool. While its effect on patient safety and resident efficiency await the results of further studies, our study shows that this tool rapidly captured the attention of resident physicians and became widely used as a valuable means to centralize and organize sign-out and daily ward work information.

ROBOTIC THYROIDECTOMY (RT), as described and applied in large numbers of patients in Korea, has been to many a revolution in modern thyroid surgery. A thyroidectomy without an incision in the neck is appealing to many patients and some surgeons. In this report, the leaders of the transaxillary robot-assisted thyroidectomy approach are comparing their novel technique with conventional open thyroidectomy (OT) and asking the question whether RT provides a better self-body image and improved quality of life (QoL) than the conventional approach. Their answer favors RT, but we are not convinced with the data presented in this paper. Of the 169 patients (all of whom were female)

IT IS CLEARLY A PRIVILEGE and a signal honor for me to serve as President of the Central Surgical Association. It is the organization where I presented my first scientific paper, and warm productive friendships with the membership have grown over the years. Wives have always been included in the social functions of this association, making the annual meetings very special events. To have carried the baton at the turn of the century, during the rejuvenation of our membership, and for the change in venue of our group has been most satisfying. I believe we all must credit our prior leadership for the innovations that have occurred. The privilege of this podium allows me to thank and recognize several individuals who have had a profound impact on my professional career. My introduction to the joys of a career in surgery came from Dr Eric M. Nanson during my medical student days. Eric Nanson was a New Zealander by birth and basic surgical education. He became the founding

WHEN THE EDITORS approached me to write a commentary on what the Robert Wood Johnson (RWJ) Clinical Scholars Program has meant to my career, I accepted immediately, assuming that it would be a fairly easy task. After all, it is safe to say that I would not be the person I am today (at least not professionally) if it had not been for the training I received in the Clinical Scholars Program and the continued support of the Foundation since then. But, when I actually sat down and put electronic pen to paper, I found the task much more challenging. As I pondered the issues, it became apparent that impact of the Clinical Scholars Program on my career has been so profound that 1,000 words might not suffice. As such, I felt it was best to focus on the formative effect the Clinical Scholars Program had on me as a surgeon–scientist. As a Clinical Scholar, I was lucky enough to be mentored by a number of truly inspirational individuals who I never would have met had it not been for the RWJ Foundation. I learned the basic principles of clinical epidemiology from one of the true fathers of the field, Alvan Feinstein. Alvan had a well-earned reputation as a tough taskmaster that rubbed some people the wrong way. He once mentioned to me that he loved having surgeons as fellows because we ‘‘could take it.’’ I replied that it was not so much that surgeons were tough; rather, we were used to having mentors in surgery who by way of their specialty demanded excellence from us at all times. Like the faculty from my residency, Alvan would not tolerate anything less than

Objective The quality of surgical care in safety net hospitals (SNHs) is not well understood owing to sparse data that have not yet been analyzed systematically. We hypothesized that on average, SNHs provide a lesser quality of care for surgery patients than non-SNHs. Study Design We performed a systematic review of published literature on quality of surgical care in SNHs in accordance with guidelines from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched within the PubMed, CINAHL, and Scopus online databases, and included peer-reviewed, English-language, scientific papers published between 1995 and 2013 that analyzed primary or secondary data on ≥1 of the domains of quality (safety, effectiveness, efficiency, timeliness, patient centeredness, and equity) of surgical care in a US hospital or system that met the Institute of Medicine definition of a SNH. Each article was reviewed independently by ≥2 co-investigators. A data abstraction tool was used to record the eligibility, purpose, design, results, conclusion, and overall quality of each article reviewed. Disagreements over eligibility and data were resolved by group discussion. The main results and conclusions abstracted from the included articles were then analyzed and presented according to the quality domains addressed most clearly by each article. Principal Findings Our initial search identified 1,556 citations, of which 86 were potentially eligible for inclusion. After complete review and abstraction, only 19 of these studies met all inclusion criteria. SNHs performed significantly worse than non-SNHs in measures of timeliness and patient centeredness. Surgical care in SNHs tended to be less equitable than in non-SNHs. Data on the safety of surgical care in SNHs were inconsistent. Conclusion Although data are limited, there seems to be need for improvement in particular aspects of the quality of surgical care provided in SNHs. Thus, SNHs should be priority settings for future quality improvement interventions in surgery. Such initiatives could have disproportionately greater impact in these lower-performing settings and would address directly any health care disparities among the poor, underserved, and most vulnerable populations in the United States.

Background. Unlike chronic calcific pancreatitis, obstructive pancreatitis occurs as a consequence of an obstruction or stricture in the main pancreatic duct. The purpose of this paper is to identify the best method of surgical treatment for patients with obstructive pancreatitis. Methods. Retrospective analysis of 224 patients surgically treated for chronic pancreatitis during a 7-year period (1988 through 1994) identified 23 patients with obstructive pancreatitis. Patients were classified by surgical treatment into pancreaticoduodenectomy (five patients), side-to-side pancreaticojejunostomy (nine patients), or distal pancreatectomy (nine patients) groups and analyzed. Results. Despite similar demographics, patients treated with distal pancreatectomy had significantly better outcomes (seven of nine) than those treated with either pancreaticoduodenectomy (zero of four) or side-to-side pancreaticojejunostomy (two of eight) at a mean follow-up of 26 months (chi-squared, p=0.009). Multivariate analysis revealed stricture location, cause of pancreatitis, maximal duct dilatation, exocrine insufficiency, or continued alcohol intake had no influence on surgical outcome in this series (p=0.698, logistic regression analysis). Conclusions. At 2 years of follow-up, distal pancreatectomy provided superior relief from pain and recurrent pancreatitis compared with pancreaticoduodenectomy or side-to-side pancreaticojejunostomy. Obstructive pancreatitis is best treated by distal rather than proximal pancreatic resection or drainage.

Background The h-index is used as an objective measure of research impact. Its validity, however, is not known in the context of general surgery and comparisons with other bibliometric indices are lacking. We sought to evaluate the h-index as a reliable and valid measure of research performance in general surgery across 6 universities in the province of Ontario, Canada. Methods Bibliometric indices for 219 faculty members in general surgery were calculated using the Scopus and Web of Science online databases. We investigated agreement between the databases. A 2-way analysis of variance was used to compare the h-index of surgeons grouped by institutional affiliation and academic rank and to identify the relative impact of these factors on different bibliometric indices. Results The agreement on h-indices between the Scopus and Web of Science was problematic. The h-index was associated more strongly with academic rank (academic rank accounted for 33.3% of researcher’s h-index) than of the number of publications (12.5%) or the number of citations per author (10.2%). The number of citations per paper was not associated with academic rank. The institutional affiliation affected bibliometric indices to a similar degree to academic rank. Conclusion Our data suggest better construct validity for the h-index than for other bibliometrics, although the agreement of h-index values between databases can be problematic for some researchers. The use of the h-index as a criterion-based assessment across different universities is problematic and that it should be used as a normative assessment tool, with comparisons with a specified population of interest.

PEOPLE MAKE MISTAKES. Human error is inevitable and must be anticipated, especially in environments where novices are developing new knowledge and skills. In medical education, faculty members are charged with supervising their residents to minimize chances of patient care errors. This is no small challenge for faculty given the consequences of errors to patients, the psychological cost to learners, and the ramifications for the faculty member and hospital from the fiscal, resource, and medicolegal perspectives. Yet, if decisionmaking and technical errors are bound to occur during a physician’s career because of human infallibility, and residents have uneven and limited exposure to errors because of responsible faculty oversight, how will they graduate fully prepared to recognize and manage an error when one does occur? Satava explained that faculty members spend so much time teaching residents how to do the correct thing that they forget to explicitly teach how to avoid errors or fix it when one has occurred. Residents encounter errors during their residency but this ‘‘catch as catch can’’ strategy cannot provide a sufficient and balanced array of opportunities to hone the perceptual, cognitive, and technical skills needed to prevent, recognize, or manage the range of potential errors. The purpose of this paper is to: (1) justify the importance of integrating planned instruction about errors into surgical residency curricula

Background This paper describes our experience with a novel method of temporary abdominal closure that permits frequent reassessment of the abdominal contents and progressive reapproximation of the fascial edges without compromising definitive fascial closure outcomes. Methods We developed a novel method of temporary abdominal closure, which we have named the frequent assessment temporary abdominal closure (FASTAC). The records of patients who underwent planned relaparotomy during 5 years were reviewed. The data collected included patient demographics, indication for operation, number of operations, duration of temporary abdominal closure placement, hospital duration of stay, method of definitive abdominal closure, and subsequent ventral hernia repair. Results One hundred and thirty-three patients underwent 308 temporary abdominal closure placements, including 16 patients who had a FASTAC placed for open abdomen management. FASTAC remained in place for a significantly greater time with more frequent reassessment. Fascial closure techniques were not different in FASTAC patients. FASTAC patients had a significantly greater duration of stay, which suggests selective placement in a more complicated patient population. The materials for frequent assessment temporary abdominal closure cost only $38 compared with $350 for a large piece of Silastic. Conclusion FASTAC is a novel, cost-effective method of temporary abdominal closure that allows for frequent bedside intra-abdominal surveillance, maintains abdominal domain, and does not compromise abdominal closure outcomes in the management of the open abdomen.

Background Approximately 300 cases of leiomyosarcoma of the inferior vena cava (IVC) have been reported in the literature to date. In this study, we combined the experience from 2 institutions to provide additional clinical outcomes data. Methods We performed a retrospective analysis from 1984 to 2009 that included 17 patients treated between the 2 institutions. Clinicopathologic data, surgical and adjuvant therapy, and survival outcomes were obtained. Results The median age of patients in the study was 48 years. The tumor location was infrarenal in 8 patients, juxtarenal in 6, and suprahepatic in 2 patients; 7 patients had high-grade tumors. All patients underwent complete resection; the IVC was repaired primarily in 5 patients, ligated in 5, and reconstructed with a prosthetic tube graft in 7 patients. There was no perioperative mortality; 6 patients had complications. Median follow-up was 49 months; median survival had not been reached when this paper was written. The 5-year overall and disease -free survival were 56% and 37%, respectively. Of the 17 patients, 10 experienced disease recurrence and underwent numerous treatment modalities for these recurrences. Conclusion Aggressive resection of primary leiomyosarcoma of the IVC can be performed safely and result in long-term survival, irrespective of IVC management. Despite high recurrence rates, no consensus yet exists regarding adjuvant treatment.

Minimally invasive liver surgery is a rapidly advancing field with demonstrated applicability to living donation. In this paper, we compare the safety and efficacy of laparoscopy-assisted donor right hepatectomy (LADRH) to open donor right hepatectomy (ODRH).We performed a retrospective, comparative analysis of 33 LADRH to the most recent 33 ODRH performed at our institution, evaluating donor complications, costs, and recipient outcomes.Donor demographics including age, gender, body mass index (BMI), and vascular and biliary anomalies were comparable. Donor complication rates were equivalent for LADRH and ODRH. Donor operative times were shorter for LADRH (LADRH 265 minutes, ODRH 316; P.001) even after adjusting for BMI. Blood loss and length of stay were comparable. Additionally, total hospitalization costs were equivalent (LADRH $1.11, ODRH $1.00; P = .19). Higher operative supply costs for LADRH were balanced by higher time-based operative costs for ODRH resulting in no significant differences in total operative costs. Finally, there were no differences in graft size, recipient patient or graft survival, or recipient vascular or biliary complications.Our experience suggests that LADRH compares favorably with ODRH with equivalent safety, resource utilization, and effectiveness. We believe that LADRH provides potential physical and psychological benefits without an adverse effect on outcomes.

Background The development of an intrathymic parathyroid adenoma is common, and thymectomy is a significant component of the parathyroid surgeon’s technical armamentarium. Over the last decade, minimally invasive parathyroidectomy (MIP) has become the standard technique for removal of an abnormal parathyroid gland, and the requirement for thymectomy should remain unchanged during the era of minimally invasive techniques. The aim of this paper was to assess the feasibility and outcomes of cervical thymectomy for intrathymic parathyroid adenomas during MIP. Methods This is a retrospective case series. The study group comprised all patients undergoing parathyroidectomy in the University of Sydney Endocrine Surgical Unit during a 5-year period (January 2001 to December 2005). Patients undergoing MIP and open parathyroidectomy with a concomitant cervical thymectomy were compared. Results A total of 840 patients underwent parathyroid surgery for primary hyperparathyroidism (PHPT) during this period. A total of 30 MIP procedures with concurrent thymectomy were performed, and 99 open bilateral neck explorations with cervical thymectomy were performed. Of the MIP thymectomy group, there were 25 female and 5 male patients; the average age was 57 years (range, 22 to 82). A mean length of 34 mm of thymus was extracted via the minimally invasive approach (range, 8 to 85 mm). In 5 cases, only fatty tissue was identified histologically, and, in 5 cases, a small supernumerary parathyroid gland was identified in the histologic specimen. Only 1 patient suffered temporary, recurrent laryngeal nerve palsy; there were no cases of postoperative hemorrhage requiring return to the operating room. Conclusions Cervical thymectomy for removal of intrathymic parathyroid adenomas can be performed during lateral focused mini-incision MIP with a safety and efficacy equivalent to open bilateral neck explorations.

In this issue of Surgery, Bugalho and colleagues from Portugal, present their experience with RET testing of patients with sporadic and familial medullary thyroid carcinoma (MTC). Although their targeted approach to RET testing for patients in whom the mutation status is unknown (presumed sporadic MTC) is not often practiced in this country (where sequencing of exons 10, 11, and 13 to 16 is commonly performed), their paper serves to emphasize the importance of ordering RET gene testing on all patients with MTC. At present, knowledge of the RET mutation status and disease extent is required to determine the correct operation for any patient with MTC. Therefore, all surgeons caring for patients with presumed sporadic or inherited MTC need to know how to obtain genetic testing of the RET proto-oncogene. Inherited MTC can occur as part of multiple endocrine neoplasia type 2 (MEN 2) syndrome. MEN 2 is an autosomal dominant inherited cancer syndrome with 3 main subtypes: MEN 2A, MEN 2B, and familial MTC (FMTC). These clinical subtypes differ from each other in the spectrum of endocrine involvement and the biologic behavior of MTC. MEN 2A is clinically defined by the presence of MTC and either pheochromocytoma or hyperparathyroidism (or both) in a single individual, or the presence of 2 or more tumor types in multiple relatives of a single family. MEN 2B is characterized by MTC and pheochromocytoma, without hyper

Background This review examines the surgical and psychological literature on surgeons' intraoperative non-technical skills. These are the critical cognitive and interpersonal skills that complement surgeons' technical abilities. The objectives of this paper are (1) to identify the non-technical skills required by surgeons in the operating room and (2) assess the behavioral marker systems that have been developed for rating surgeons' non-technical skills. Methods A literature search was conducted against a set of inclusion criteria. Databases searched included BioMed Central, Medline, EDINA BIOSIS, Web-of-Knowledge, PsychLit, and ScienceDirect. Results A number of “core” categories of non-technical skills were identified from 4 sources of data: questionnaire and interview studies, observational studies, adverse event analyses, and the surgical education/competence assessment literature. The main skill categories were communication, teamwork, leadership, and decision making. The existing frameworks used to measure surgeons' non-technical skills were found to be deficient in terms of either their psychometric properties or suitability for rating the full range of skills in individual surgeons. Conclusions Further work is required to develop a valid taxonomy of individual surgeons' non-technical skills for training and feedback.

As part of efforts afoot to improve the overall quality of physician training, the Accreditation Council for Graduate Medical Education (ACGME) has endorsed a set of competencies that will be the blueprint for outcomes-based graduate medical education for years to come. While the spirit of this new law is taking shape, the letter remains largely unwritten. To bridge this gap, administrators of programs from all specialties must determine how the core competencies will be taught, evaluated, modeled, and enforced within their respective programs. This paper summarizes these challenges, in particular for surgical programs, and focuses constructively on the modeling/enforcement approach, describing key characteristics that programs should pursue and cultivate (virtues) as well as the signal prohibitions (vices) that both trainees and trainers must avoid. Regardless of specialty or programmatic particulars, virtues and vices may be used to define a context in which general competencies may be understood, and yield operational guidance upon which ultimate discussions of evaluation, remediation, and graduation may be predicated.