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Physician wellness has become an increasing focus of attention in recent years as burnout among healthcare professionals appears to be on the rise. Within this review, we attempt to define burnout and describe the ways in which resident well-being is being addressed within surgical residency programs. Burnout is a psychological construct, defined by emotional exhaustion, depersonalization, and a low sense of personal accomplishment, which has been shown to affect physicians beginning in their medical training. In spite of mounting evidence of the negative effects of burnout on physicians’ personal and professional lives, there is relatively little evidence on how best to address this increasingly pervasive problem. We categorize various ways in which individual surgical residency programs attempt to improve the well-being of their trainees. Little consensus exists on how best to improve wellness for surgical trainees. Multiple individual programs have focused on a variety of interventions whose efficacy remains largely unproven. Increased standardization of burnout research with greater collaboration across institutions is needed in order to identify key wellness initiatives.

A 45-year-old woman was referred to our clinic in 2014 for evaluations of a recurrent hepatic cyst incidentally discovered by computed tomography (CT) scan approximately 10 years prior to referral. Since its radiographic appearance was consistent with a simple cyst, no intervention was recommended. She developed right upper quadrant and epigastric pain in 2011, prompting a repeat CT scan that demonstrated the diameter of the cyst to have increased to *12 cm. Though it was still thought to be a simple cyst, given her new symptoms and modest growth in cyst size, she underwent a laparoscopic cyst fenestration with biopsy of the cyst wall. Although the final pathological examination revealed a hepatobiliary cystadenoma with ovariantype stroma, no action was taken beyond surveillance. Symptoms recurred after her operation; the abdominal pain intensified after she became pregnant. Magnetic resonance imaging (MRI) repeated in 2013 demonstrated a 14-cm hepatic cystic mass with a thin septation. Complete blood count and comprehensive metabolic panel were normal with the exception of a mildly elevated serum alkaline phosphatase (140 l/mL). Serum cancer antigen 19–9 was slightly elevated (70 l/mL). A repeat MRI at our hospital showed a large cyst in the center of the liver with perihilar mass effect and mild intrahepatic biliary ductal dilation. The cyst was located at the bifurcation of the right and left hepatic pedicles with more profound distortion of the left (Fig. 1). She appeared healthy without jaundice with a benign abdominal examination. Based on the pathology from her initial operation and the relentless cyst growth, an extended left hepatectomy was recommended for definitive resection. The patient elected to wait a year until her child was older prior to undergoing the operation. At surgery in 2015, intraoperative ultrasound was consistent with the previous CT scan in that the cyst had internal debris without clear solid components (Fig. 2). The liver parenchyma was carefully divided in the plane between the cyst wall and the segment 5 and 8 pedicles in efforts to enucleate the cyst and preserve these pedicles to the right lobe of the liver (Fig. 3). The gross specimen contained a 13.5-cm cyst with no mural nodularity (Fig. 4). Pathology demonstrated a mucinous cystic neoplasm with low-grade dysplasia. Her postoperative recovery was uncomplicated.

The purpose of this pictorial essay is to showcase the use of minimum intensity projection in the imaging of low attenuation structures such as the pancreatic duct. Minimum intensity projection is a valuable adjunct to other processing techniques for the diagnosis and staging of pancreatic adenocarcinoma and cystic tumors of the pancreas.

Tumors in the stomach have traditionally been treated with either subtotal gastrectomy or total gastrectomy, depending on the location. However, many of these lesions are benign spindle cell tumors or adenomas and could be resected with margins. Here, we explore multiple minimally invasive methods for the resection of these tumors. We highlight a wedge resection, a circumferential resection with transverse closure, a transgastric resection, and an endoscopic/laparoscopic submucosal resection. The wedge resection was performed in a 71-year-old man found to have a mass in the stomach on screening upper endoscopy. The biopsy was not definitive, but on CT scan there was a 4.5-cm submucosal mass consistent with a gastrointestinal stromal tumor. The circumferential resection was performed for an 83-year-old woman who had abdominal discomfort which led to an upper endoscopy. She was found to have a mass in the lesser curve of her stomach. Biopsy revealed this to be a gastrointestinal stromal tumor. Ultimately, it was removed when serial CT scans showed that it was growing. The transgastric approach was used for a 75-year-old man who had upper endoscopy for reflux symptoms and was found to have a mass in the stomach. Biopsy showed that it was a gastrointestinal stromal tumor. Due to patient preference, it was initially observed but was eventually removed when it was found to be growing on serial CT scans. The endoscopic/laparoscopic approach was for a 65-year-old man who had an upper endoscopy performed for work-up of melena and was found to have a 5-cm mass at the gastroesophageal junction. The biopsy showed this to be an adenoma, and he went on to have it removed.We identified representative videos from patients treated with each of the above techniques. Small exophytic lesions can be completely excised with a wedge resection using a stapler to fire across the base of the lesion. By contrast, if the lesion is in an awkward location or is too large to remove in this way, a vessel-sealing device can divide the mass from the stomach circumferentially (intragastric resection). The resultant defect in the gastric wall must be repaired transversely to avoid narrowing the lumen. Endophytic lesions can be treated with transgastric resection. Ports are placed directly into the stomach allowing excision from within the stomach. Finally, submucosal resection is ideal for lesions close to the GE junction. This combined endoscopic and laparoscopic approach allows the tumor to be lifted off the muscle fibers and to be resected without transmural injury to the stomach or esophagus.All four patients tolerated the procedure well and were discharged home by postoperative day 2. There were no complications. One patient, the one who underwent the endoscopic/laparoscopic approach and was preoperatively found to have an adenoma on biopsy, was ultimately found to have an invasive component and later underwent total gastrectomy. The other three patients all had gastrointestinal stromal tumors.Minimally invasive techniques should be considered more frequently for the management of benign gastric tumors. The four methods illustrated here can be used safely and result in faster recovery as well as shorter hospital stays compared to traditional approaches.