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There has been concern expressed amongst the medical educational community regarding the readiness of general surgery residents in the United States to be competent practicing attendings upon graduation and that limited autonomy may be a contributing factor to this unpreparedness. The purpose of this study was to evaluate an RRC-accredited general surgery residency chief resident acute care surgery service with indirect supervision of cases in terms of safety and outcomes compared to traditional general surgeon cases with direct supervision. The study focused on common general surgical procedures, specifically cholecystectomies, appendectomies, and inguinal and ventral hernia repairs.A retrospective review was conducted of patient data from August 2016 to June 2018 to review all patients 16 years old and older who had received one of the following procedures: appendectomy, cholecystectomy, inguinal hernia repair, or ventral hernia repair. Patient characteristics, procedure type, procedure time, estimated blood loss, complications, length of hospital stay, 30-day readmission, 30-day ED visit, need for reoperation, and mortality were compared between attending direct supervision and chief resident indirect supervision surgery services.A single institution associated with a community based-university associated hybrid general surgery residency was included in this study.Patients aged 16 years or older who underwent one of the operations of interest and were discharged between the dates of August 2016 and June 2018. The operations were performed by, or indirectly supervised by, attendings who were both private surgeons and also covered the chief resident service.A total of 1000 cases were reviewed, with a total of 960 included in the final data after exclusions applied. Of the 960 cases included, 68.4% were traditional attending surgeon cases with direct supervision and 31.6% were chief resident service cases with indirect supervision. A total of 161 appendectomies, 396 cholecystectomies, 201 inguinal hernias and 202 ventral hernias were included. Overall, patients in the chief resident service were more often minorities (27.7 vs. 9.4%, p0.001), female (56.4 vs. 44.6%, p = 0.001), younger (40 vs. 55 years, p0.001), had a higher BMI (31.2 vs. 29.6, p = 0.018), and a lower ASA class (class 1+2 was 86.4 vs. 65.6%, p0.001). The median Charleson Comorbidity Index of the chief resident service patients was lower than that of the attending service (0 vs. 2, p0.001). Chief resident service cases were also more often urgent cases (40.6 vs. 22.8%, p0.001). Overall, the 30-day complication rate was similar between the two services (5.6 vs. 5.8%, p = 1.000). Complications observed from chief resident service and attending service supervised cases included pneumonia (0.3 vs. 0.5%, p = 1.000), surgical site infection (2.3 vs. 1.5%, p = 0.389), UTI (1.0 vs. 0.6%, p = 0.685), acute kidney injury (0.0 vs. 0.8%, p = 0.333), small bowel obstruction (0.0 vs. 0.6%, p = 0.314), cerebrovascular accident (0.0 vs. 0.2%, p = 1.000), and hematoma/seroma (2.3 vs. 1.7%, p = 0.500). There were no statistically significant differences in procedure-specific complications between services. There was one 30-day mortality in the study population, in the attending service group.This study's data suggest that a chief resident acute care surgery service with indirect supervision of cases is safe in this community with regards to appendectomies, cholecystectomies and hernia repairs.

Background Aging remains one of the greatest risk factors for development of new breast cancer with more than 30% of breast cancers occurring after the age of 75. Elderly women have been found to not conform with all aspects of treatment recommendations. Our study compared outcomes of elderly breast cancer patients whose treatment did or did not conform to NCCN guidelines. Methods A retrospective review was conducted of breast cancer patients over the age of 70. Comparisons were made between patients whose treatment did or did not conform to NCCN guidelines for recurrence, metastatic disease, and breast cancer related deaths. Results Patients whose treatment did not conform to NCCN guidelines were older (80.5 vs. 77.7 years, P = 0.001). No significant difference was seen between groups for tumor size, breast cancer type, or nodal status; however, more nonconforming women were ER/PR positive (90.3% vs. 76.6%, P = 0.020). There was no significant difference in local recurrence, metastatic disease, or breast cancer related deaths. Conclusions Women whose treatment did not conform to NCCN guidelines were not associated with worse outcomes.

Purpose: This study examined the safety and efficacy of placing both a central venous dialysis catheter and a central venous catheter for infusion in the right internal jugular vein compared to only a central venous dialysis catheter. Methods: We conducted a retrospective chart review for all adult patients who underwent the placement of the right internal jugular dialysis catheter by a single surgeon. Patients were grouped based on whether they received a tunneled dual lumen dialysis catheter alone or in combination with a central venous infusion catheter in the right internal jugular vein. Catheter-related thrombosis, line infections, line malfunctions, pneumothorax, and need for line replacement were evaluated. Results: There were 97 patients in the dialysis catheter and central venous infusion line group and 63 patients in the dialysis catheter only group. The two groups were not different with regard to age (62.1 ± 16.3 years vs 57.9 ± 17.6 years) and gender (47.4% male vs 55.6% male). No significant differences were found in the incidence of thrombosis (1.0 % vs 0.0%, p > 0.999), line infection (2.1% vs 0.0%, p = 0.519), or line malfunctions (2.1% vs 0.0%, p = 0.516) in patients who did or did not have a central venous infusion catheter placed concomitantly with the dialysis catheter, respectively. No patients in either group had a pneumothorax. Conclusions: Although not currently utilized with frequency, these preliminary data indicate that placing both a dual lumen dialysis catheter and central venous infusion catheter in the right internal jugular simultaneously could be a viable option.

The purpose of this study was to determine if thromboelastography (TEG) is associated with reduced blood product utilization for trauma patients undergoing massive transfusion protocol (MTP) compared to traditional coagulation tests.A retrospective review was conducted on an intent-to-treat basis of trauma patients undergoing MTP (Pre-TEG = Period I vs. Post-TEG = Period II). Traditional coagulation tests guided transfusion during Period I (n = 20) and the intent was that TEG guided transfusions during Period II (n = 47). Blood product administration and outcomes were compared.Intent-to-treat analysis demonstrated a significant reduction in red blood cell transfusions (11 vs. 6 units, P = 0.001), number of patients receiving fresh frozen plasma (85.0 vs. 17.0%, P 0.001), and platelets (75.0 vs. 38.3%, P = 0.006) in Period II. No difference was seen between Periods I and II in ICU days (7.0 vs. 11.0 days, P = 0.073), hospital length of stay (10.5 vs. 14.0 days, P = 0.618), or mortality (55.0 vs. 31.9%, P = 0.076).Use of TEG-guided transfusion in the critically-ill trauma patient conserved blood product utilization and appears to offer similar outcomes when compared to traditional coagulation tests.

Background Critical access hospitals (CAH) serve a key role in providing medical care to rural patients. The purpose of this study was to assess effectiveness of CAHs in initial care of trauma patients. Methods A 5-year retrospective review was conducted of all adult trauma patients who were transported directly to a level I trauma facility or were transported to a CAH then transferred to a level I trauma facility after initial resuscitation. Results Of 1478 patients studied, 1084 were transferred from a CAH with 394 transported directly to the level I facility. Patients transported directly to the level I hospital were younger and more severely injured. After controlling for injury severity score, age, GCS, and shock, the odds of mortality did not differ between CAH transfer patients and patients transported directly to a level I facility (OR 0.70, P = 0.20). Transfer from CAH was associated with decreased ICU and hospital days, but not associated with increased ventilator days. Conclusion This study demonstrates that use of a CAH for initial trauma care in rural areas is effective.

Background The specific contribution of dementia towards mortality in trauma patients is not well defined. The purpose of the study was to evaluate dementia as a predictor of mortality in trauma patients when compared to case-matched controls. Methods A 5-year retrospective review was conducted of adult trauma patients with a diagnosis of dementia at an American College of Surgeons-verified level I trauma center. Patients with dementia were matched with non-dementia patients and compared on mortality, ICU length of stay, and hospital length of stay. Results A total of 195 patients with dementia were matched to non-dementia controls. Comorbidities and complications (11.8% vs 12.4%) were comparable between both groups. Dementia patients spent fewer days on the ventilator (1 vs 4.5, P = 0.031). The length of ICU stay (2 days), hospital length of stay (3 days), and mortality (5.1%) were the same for both groups (P > 0.05). Conclusions Dementia does not appear to increase the risk of mortality in trauma patients. Further studies should examine post-discharge outcomes in dementia patients.

Background Recent literature suggests the majority of traumatic intracranial hemorrhage does not require intervention. One recently described clinical decision rule was sensitive in identifying patients requiring critical care interventions in an urban setting. We sought to validate its effectiveness in our predominately rural setting. Methods A retrospective study was conducted of adult patients with traumatic intracranial hemorrhage. The rule, based on age, initial Glasgow coma scale score, and presence of a non-isolated head injury, was applied to externally validate the previously reported findings. Results In our population, the rule displayed a sensitivity of 0.923, specificity of 0.251, positive predictive value of 0.393, and negative predictive value of 0.862. The area under curve was 0.587. While our population has a similar adjusted head injury severity score as that from which the rule was developed, significant differences in age and intracranial hemorrhage pattern were noted. Conclusions The rule displayed decreased performance in our population, most likely secondary to differences in age and intracranial hemorrhage patterns. Prospective evaluation and cost-savings analysis are appropriate subsequent steps for the rule.

Rural surgeons are performing operations typically performed by "specialists." This study describes specialty procedures performed by general surgeons operating in a rural state and how prepared the surgeons felt starting their rural practice after residency A survey was sent to all exclusively rural surgeons actively practicing in the state, inquiring about their perception of preparedness for rural practice and specialty procedures performed. The survey had a 65.2 per cent response rate. Responders felt well prepared for rural practice after residency (mean response 4.6 ± 0.8 on a Likert scale from 1 to 5; 5 = "well prepared"). Noteworthy, specialty procedures performed by rural surgeons included hysterectomies (51.2%), thyroidectomies (81.4%), parathyroidectomies (60.5%), carotid endarterectomies (11.6%), video-assisted thoracoscopic surgery (37.2%), and lobectomies (23.3%). Prominent write-ins included nephrectomies (n = 1), ileal conduits (n = 1), open and endovascular abdominal aortic aneurysm repair (n = 1), Whipples (n = 3), and liver resections (n = 2). Rural general surgeons perform many major operations usually performed by specialists. These surgeons felt well prepared for these operations out of residency.

Survivors of near-hangings suffer anoxic brain injuries, but it remains uncertain whether the incidence of associated injuries warrants extensive workup or trauma activation. An 11-year retrospective review was conducted on adult patients with a hanging mechanism who underwent trauma workup and management. The majority of patients (n = 98) were white (88.8%) males (75.5%) with an average age of 30 ± 12.3 years. Two-hundred fifty-four CT and magnetic resonance scans were performed and eight injuries were uncovered: three thyroid cartilage/hyoid fractures; three vertebral injuries; and two cervical vascular injuries. Anoxic brain injury was diagnosed clinically in 35 patients (35.7%) and was present in all 19 patients (19.4%) who died. Only one patient had intra-abdominal injury requiring surgical intervention. Injuries were more likely in patients with abnormal Glasgow Coma Scale (GCS)

Background This study aimed to determine the incidence of intra-abdominal injuries in elderly patients after a ground-level fall. Methods A 6-year retrospective review was conducted on patients 65 years of age or older involved in a fall from standing and evaluated at a level 1 trauma center. Each patient presented with a pelvic, thoracolumbar, and/or lower rib fracture. Data collection included demographics, injury characteristics, FAST exam results, CT imaging results, and hospitalization outcomes. Results A total of 324 patients met study inclusion criteria. The majority of patients were white (95.1%) females (65.4%) with an average age of 82.0 ± 7.3 years. Only 22 patients (6.8%) reported abdominal pain, although an abdominal CT was performed in 91 patients (28.1%). Only 1 patient (0.3%) was found to have an intra-abdominal injury when no abdominal pain was reported and the FAST exam was negative. This injury was not clinically significant enough to warrant surgical intervention. Conclusion Elderly patients who suffer a ground-level fall do not benefit from PAN-SCAN, even when presenting with rib, thoracolumbar, and/or pelvic fractures.

Agricultural work results in numerous injuries and deaths. Efficacy of farm equipment safety interventions remains unclear. This study evaluated agricultural mortality pre- and postimplementation of safety initiatives. A 31-year retrospective review of mortality data from agriculture-related injuries was conducted. Demographics and injury patterns were evaluated by mechanism of injury. There were 660 deaths (mean age 48.6 years). Female deaths increased from 5.2 to 11.7 per cent (P = 0.032). Mortality associated with tractors decreased (75.6% vs 53.9%; P0.001) and with all-terrain vehicles increased (3.5% vs 22.0%; P0.001) from Period I to III. However, tractors remain the primary cause of mortality. For mechanical equipment-associated mortality, there was a decrease (83.3% vs 50.0%) in "caught in equipment," and an increase (6.7% vs 38.9%) in those killed by "crush injury" from Period I to III. Application of safety devices to enclose and stabilize machinery has led to an overall decrease in mortality associated with tractors and "caught in equipment." Expanded rural education, as well as further development and use of safety devices, is warranted to curtail farm-related injuries and deaths.

Background Children with confirmed brain injury usually undergo follow-up computed tomography (CT) scan of the head within 24 hours of admission. To date, no evidence exists to validate the diagnostic or therapeutic value of these repeat CTs. The purpose of this study was to (1) evaluate progression of traumatic brain injuries, (2) determine if routine repeat imaging changes management, and (3) compare the efficacy of recognizing worsening hemorrhage with serial neurological examination versus repeat imaging. Methods A 5-year retrospective review was conducted of all patients aged under 18 years with blunt traumatic head injury (n = 95). Data included demographics, type and size of intracranial hemorrhage, exam findings, diagnostic and management changes, and hospital outcomes. Results Most patients (68.4%) had at least one repeat CT; of these, 67.7% (n = 44) showed no change or reduced hemorrhage. In only one patient did a repeat CT scan result in a surgical procedure; however, that CT scan was prompted by a change in neurological status. Among patients with more than two repeat head CTs, 42.9% led to a change in management, most frequently an additional CT scan. Presence of neurological symptoms was associated with having repeat CT scans (p = 0.025). Changes in Glasgow Coma Scale score were associated with increased hemorrhage (p = 0.012) but not repeat scans (p = 0.496). In the majority of cases, increased hemorrhage only resulted in an additional head CT and prolonged intensive care unit stay. Excluding patients who arrived with brain death, there was no difference in mortality between patients with and without repeat imaging. Conclusion Findings from this study support a selective approach for repeating head CTs with emphasis on changes in neurological symptoms and Glasgow Coma Scale score. Prospective studies on timing and indications for repeat CT scans are needed to support development of clinical guidelines. Level of evidence Therapeutic study, level III.

Background When retained hemothorax occurs, video-assisted thoracoscopy or thoracotomy is performed, but recently, tissue plasminogen activator (tPA) has been used. This study evaluated intrapleural tPA use for retained traumatic hemothoraces. Methods A retrospective review was conducted of trauma patients treated with intrapleural tPA for retained hemothorax. Data included demographics, past medical and surgical histories, injury details, treatment details, and outcomes. Results Seven patients (median age=47 years, male=6, blunt trauma=6) met study criteria. All patients received a chest tube. Six patients later received computed tomography-guided drains for tPA infusion. Number of tPA treatments per patient varied from 1 to 5. Median total tPA dosage was 24 mg. Median time from injury to chest tube placement was 11 days and from chest tube placement to first tPA treatment was 4 days. No patients required a video-assisted thoracoscopy; however, 1 patient required thoracotomy. There were no deaths or bleeding complications attributed to intrapleural tPA. Conclusion Although future studies are needed to identify optimum treatment guidelines, intrapleural tPA appears to be a safe and efficacious treatment option.

Background There is a lack of information regarding the safety, complication rate, and cosmetic outcome of oncoplastic breast conserving surgery. The purpose of this study is to evaluate and compare oncoplastic and nononcoplastic procedures. Methods A retrospective review was conducted of patients treated with oncoplastic or nononcoplastic lumpectomies. Immediate and long-term complication rates and cosmetic satisfaction were compared. Results Of the 142 surgeries, 58 were oncoplastic lumpectomies (40.8%). Oncoplastic patients were younger than nononcoplastic patients (60.9 vs 65.2 years, P = .043). Immediate complications were similar with the exception of nonhealing wounds (oncoplastic = 8.6% vs nononcoplastic=1.2%, P = .042). Cosmetic complaints were similar, but fat necrosis was more common in the oncoplastic group (25.9% vs 9.5%, P = .009). Time to radiation and number of future biopsies were similar between the groups. Conclusion Oncoplastic lumpectomy is a safe alternative to standard lumpectomy for selected breast cancer patients.

Traumatic soft tissue, or "degloving" injuries from trauma are common. These injuries are a result of shearing and disrupt tissue planes, such as the junction between muscle and bone. Traditional repair involves debridement followed by skin grafting or flap reconstruction. Many degloving injuries, however, extend to bone or tendon and the decreased vascularity of the wound bed can compromise the success of traditional repairs. Additionally, medical comorbidities make some patients poor candidates for flap reconstruction. The purpose of this study was to evaluate the success of a dermal regeneration template in the treatment of complex traumatic degloving injuries at an American College of Surgeons verified Level 1 Trauma Center. A retrospective review was conducted on all patients sustaining traumatic degloving injuries from January 2009 to July 2010, who were treated with Integra Dermal Regeneration Template followed by split-thickness autografting. Medical records were reviewed and patient demographics, injury characteristics, comorbidities, hospital course, and outcomes were summarized. Ten patients were studied. All had traumatic degloving injuries of an extremity ranging from 50 to 1000 cm. Nine had injuries extending to bone and/or tendon. After debridement, patients underwent placement of Integra followed by a split-thickness skin graft. Of the 10 patients nine had complete take of their grafts with excellent cosmetic and functional results. Degloving injuries are common in trauma. These injuries often extend to tendon and bone, which poses challenges to repair because of decreased vascularity. Placement of a dermal regeneration template followed by a split-thickness autograft is a viable alternative to traditional methods of repair.

Background Although use of preoperative chemotherapy for breast cancer is increasing, resultant changes in breast architecture have not been described. The purpose of this study was to examine breast architecture changes in response to chemotherapy by the placement of 4 peripheral clips. Methods In a prospective case-series of breast cancer patients selected to undergo preoperative chemotherapy, 4 clips were placed peripherally to each mass using sonographic guidance. Mammograms documented tumor size and clip locations both before chemotherapy and after chemotherapy. Percentage reduction in area was calculated based on the tumor dimensions and distances between clips. Results In 16 participants, 87.5% of lesions had a significant response to chemotherapy. Changes in clip measurements varied widely from significant reduction to significant increase and did not correlate with changes in tumor size. The Pearson correlation coefficient comparing changes in tumor size and clip measurements was .036 ( P = .895). Conclusions There was no correlation between reduction in tumor size and change in clip measurements. Further research should be conducted using noncompression breast imaging modalities to eliminate possible distortion caused by mammographic compression.

Background Atrial fibrillation occurs after approximately 25% to 45% of coronary artery bypass graft (CABG) surgeries. Oxidative stress and related electrophysiological remodeling has been proposed as a potential cause of this atrial fibrillation. Perioperative supplementation of the antioxidant ascorbic acid has been evaluated as a preventive agent. The current investigation was conducted to evaluate the efficacy of ascorbic acid in reducing atrial fibrillation in CABG patients. Methods A prospective, randomized, placebo-controlled, triple-blind, single-institution study was conducted in nonemergency CABG patients. Subjects were monitored for episodes of arrhythmia and other complications. Results Eighty-nine treatment and 96 control subjects completed the study protocol. Demographics, comorbidities, and preoperative drugs were similar between groups. Surgical characteristics and postoperative medication use also were similar. The incidence of atrial fibrillation was 30.3% in the treatment group and 30.2% in the control group ( P = .985). No difference was found in postoperative complications or mortality. Conclusions Our data indicate that supplementation of ascorbic acid in addition to routine postoperative care does not reduce atrial fibrillation after coronary artery bypass grafting.

Background The purpose of this study was to assess how the practice patterns of breast surgeons affect their income and job satisfaction. Methods A 19-question survey regarding practice patterns and income and job satisfaction was mailed to all active US members of the American Society of Breast Surgeons. Results There were 772 responses. An increasing percentage of breast care was associated with lower incomes ( P = .0001) and similar income satisfaction ( P = .4517) but higher job satisfaction ( P = .0001). The increasing proportion of breast care was also associated with fewer hours worked per week ( P = .0001). Although incomes were lower in surgeons with a higher proportion of their practice in breast care, income satisfaction was not affected. Conclusions Although cause and effect relationships between income and breast surgery are difficult to establish, several trends do emerge. Most significantly, we found that dedicated breast surgeons have higher job satisfaction ratings and similar income satisfaction despite lower incomes.

Background The Residency Review Committee requires that 65% of general surgery residents pass the American Board of Surgery qualifying and certifying examinations on the first attempt. The aim of this study was to identify predictors of successful first-attempt completion of the examinations. Methods Age, sex, Alpha Omega Alpha Honor Medical Society status, class rank, honors in third-year surgery clerkship, interview score, rank list number, National Board of Medical Examiners/United States Medical Licensing Examination scores, American Board of Surgery In-Training Examination scores, resident awards, and faculty evaluations of senior residents were reviewed. Graduates who passed both examinations on the first attempt were compared with those who failed either examination on the first attempt. Results No subjective evaluations of performance predicted success other than resident awards. Significant objective predictors of successful first-attempt completion of the examinations were Alpha Omega Alpha status, ranking within the top one third of one's medical student class, National Board of Medical Examiners/United States Medical Licensing Examination Step 1 (>200, top 50%) and Step 2 (>186.5, top 3 quartiles) scores, and American Board of Surgery In-Training Examination scores >50th percentile (postgraduate years 1 and 3) and >33rd percentile (postgraduate years 4 and 5). Conclusions Residency programs can use this information in selecting residents and in identifying residents who may need remediation.

Background Available evidence indicates that there will be a general surgical workforce shortage in the future. Methods A 21-question survey instrument was mailed to all general surgery residency programs in the United States. Results A total of 1,169 residents responded. Seventy-eight percent of respondents anticipate pursuing fellowship training and thereby narrowing their scope of practice. Both male and female residents indicate that lifestyle is important in their decision-making process for choosing a fellowship and in the choice of practice type. Our data revealed that female residents anticipate working fewer hours, taking less emergency call, taking more extended leaves of absence, and retiring earlier than their male counterparts. Conclusions Evaluation of the health care system's future needs continue to be difficult. However, available evidence points to a shortfall in the general surgery workforce. An evaluation of our capacity to train new general surgeons should be performed to meet future demands.

Surgical decompression of various trigger sites has been shown by two authors to relieve migraine headaches. The purpose of this study was to evaluate the effectiveness of surgical decompression of multiple migraine trigger sites in a clinical practice setting, and to compare the results to those previously published.A retrospective, descriptive analysis was performed on 18 consecutive patients who had undergone various combinations of surgical decompression of the supraorbital, supratrochlear, and greater occipital nerves and zygomaticotemporal neurectomy performed by a single surgeon. All patients had been diagnosed with migraine headaches according to neurologic evaluation and had undergone identification of trigger sites by botulinum toxin type A injections.The number of migraines per month and the pain intensity of migraine headaches decreased significantly. Three patients (17 percent) had complete relief of their migraines, and 50 percent of patients (nine of 18) had at least a 75 percent reduction in the frequency, duration, or intensity of migraines. Thirty-nine percent of patients have discontinued all migraine medications. Mean follow-up was 16 months (range, 6 to 41 months) after surgery. One hundred percent of participants stated they would repeat the surgical procedure.This study confirms prior published results and supports the theory that peripheral nerve compression triggers a migraine cascade. The authors have verified a reduction in duration, intensity, and frequency of migraine headaches by surgical decompression of the supraorbital, supratrochlear, zygomaticotemporal, and greater occipital nerves. A significant amount of patient screening is required for proper patient selection and trigger site identification for surgical success.

Background: In July 2003, the American Council for Graduate Medical Education (ACGME) required residency programs to significantly restrict resident work hours. The effect of these regulations on trauma services has not yet been investigated. The purpose of this study was to evaluate the effect of the ACGME regulations on the care of injured patients and resident education. Methods: A 24-question instrument was mailed to a sample of senior trauma surgeons. Results: Shift work has become significantly more common among trauma residents since July 2003 (14% vs. 53.4%, (P

Background This study was designed to determine the effectiveness of Hemaseel APR fibrin sealant versus conventional drain placement in the prevention of seromas after breast procedures. Methods A prospective, randomized, controlled study of subjects who were randomized into control (drain) and experimental (fibrin) groups was conducted. Results Analysis of 82 patients showed similarly matched groups. Seroma formation rate was 45.5% in the control group and 36.8% in the fibrin glue group (P = 0.43). The rate of wound complications was similar. Aspirate volumes were significantly greater in the fibrin glue group. Drain placement saved patients >$366 over fibrin glue. Conclusions Although use of fibrin sealant resulted in a nonsignificant decrease in seroma formation rate compared with that of drain placement, the higher cost involved, cumbersome technique, and higher aspirate volumes tend to indicate that there is no advantage to using fibrin glue over drain placement with the technique described.

Background Aberrations in calcium homeostasis are common in critically ill patients. The proper method to evaluate this issue in surgical patients has not been completely defined. Methods Medical records of patients admitted to a university-affiliated, tertiary-care surgical intensive care unit were retrospectively reviewed. Calcium status was evaluated by ionized levels and as a function of serum calcium levels corrected for albumin aberrations. Results Corrected serum calcium values failed to accurately classify calcium status in 38% of cases. The sensitivity and specificity of the corrected serum calcium formula to evaluate hypocalcemia were 53% and 85%, respectively. Corrected serum values underestimated the prevalence of hypocalcemia and overestimated the prevalence of normocalcemia. No factors were able to discern which patients could be evaluated by corrected serum calcium levels. Conclusions Calcium homeostasis should be evaluated by ionized calcium levels rather than as a function of serum calcium and albumin levels.

Introduction: The potential consequences of obesity in trauma patients are significant, yet incompletely defined by previous studies. Objectives: To evaluate the effect of obesity on morbidity and mortality among injured patients. Methods: Medical records of all trauma patients evaluated at an American College of Surgeons verified Level I trauma center over a 1-year period were retrospectively reviewed. Morbidity and mortality were assessed after patients were stratified according to body mass index (BMI=kilograms/meters 2 ) and injury severity score. Results: The mortality of patients with a BMI ≥35 (obese patients) was 10.7% versus 4.1% for patients with a BMI

Recent research suggests that women older than 70 years of age with early breast cancer who choose lumpectomy may forgo radiation if they take antihormonal medication. However, many elderly patients choose to forgo both radiation and hormonal therapy. This study assessed treatment compliance in elderly patients with breast cancer. A retrospective review was conducted of patients with new-onset breast cancer older than 70 years of age. Patients were stratified by age (70 to 79 vs 80 years or older) and surgical procedure (lumpectomy vs mastectomy). Ninety-seven patients were included; 47 were aged 70 to 79 years, whereas 50 were aged 80 years or older. Treatment recommendations were similar between age groups; however, patients aged 80 years or older were more often noncompliant with recommendations for surgery (14.9 vs 0.0%, P = 0.012), radiation therapy (64.0 vs 16.0%, P = 0.001), and hormonal therapy (53.3 vs 22.6%, P = 0.013). When stratified according to surgical procedure, women aged 80 years or older receiving lumpectomy were overall more noncompliant (50.0 vs 14.8%, P = 0.014) than younger women. Women older than 80 years of age who elected for lumpectomy treatment were significantly less likely to receive standard recommendations of adjuvant hormonal or radiation therapy. The reasons for this vary and it is unknown whether this impacts their local recurrence or survival rate.

Background Head injuries are common in the pediatric population, but when an isolated skull fracture is found, there are no guidelines for repeat imaging. This study evaluated the need for repeat head computed tomography (CT) for isolated skull fracture. Methods A 10-year retrospective review was conducted of patients 17 years and younger with isolated skull fractures. Data included demographics, injury severity score (ISS), fracture location, clinical indicators of head trauma, intracranial hemorrhage, and mortality. Results Of the 65 patients in this study, mean age was 4.2 years, ISS was 7.2, and head/neck abbreviated injury score was 2.3. Most injuries were from falls (69.2%) and motor vehicle collisions (23.1%). The most common clinical indicators associated with skull fractures were nonfrontal scalp hematoma (40.0%), severe mechanism (30.8%), and loss of consciousness (30.8%). One patient who developed intracranial hemorrhage after the initial head CT showed no bleed. There were no deaths. Conclusion Isolated skull fractures in the pediatric population do not necessitate a repeat head CT as long as they do not develop worsening clinical indicators of head injury.

Background In 2006, the Residency Review Committee for Surgery increased the total number of required endoscopy cases for graduating residents. Our goal was to evaluate general surgery resident competency in endoscopy, focusing on quality measures. Methods A 9-year retrospective review was conducted of 29 residents. Total number of endoscopies performed throughout residency was recorded. Procedures performed as fifth-year residents with indirect supervision were evaluated for quality measures. Results An average of 76 esophagogastroduodenoscopies and 147 colonoscopies were performed through their first 4 years of residency. Chief residents performed an average of 16 esophagogastroduodenoscopies and 22 colonoscopies. Of colonoscopies performed during their fifth year, 191 were performed while the resident had only indirect supervision. During these cases, cecal intubation was achieved in 90.6% of cases, an average of .48 polyps were identified, and average scope withdrawal time was 13.4 ± 7.1 minutes. Conclusions Our data indicate that surgery residents achieve competency in colonoscopy before performing 140 colonoscopies, supporting the concept that surgery residencies can function as an excellent training ground for endoscopy.

Some medical school training consists of oral examinations.We conducted a 9-year review of third-year medical student examinations including oral examinations, National Board of Medical Examiners Surgery Subject Examination (SSE, ie, shelf), and United States Medical Licensing Examinations Step 1 and Step 2.Step 1 showed a moderate to strong association with Period 1 orals (Somers' D = .297, P .001), but not Period 2 orals (Somers' D = .048, P = .053). Period 1 orals (percentage) had a strong association with SSE (Somers' D = .356, P.001) and Step 2 (Somers' D = .368, P.001). Period 2 orals (pass/fail) suggested a positive, but not statistically significant, association with SSE (Somers' D = .334, P = .085) and Step 2 (Somers' D = .370, P = .055). Step 1 shows a strong association with SSE (Somers' D = .490, P.001). SSE showed a strong association with Step 2 (Somers' D = .506, P.001).Orals can be used to identify students who may have difficulty passing the SSE. Step 1 can be used to identify students at risk of poor performance on the SSE, and SSE can be used to identify students at risk for poor performance on Step 2.

Background: Autologous greater saphenous vein is considered to be the optimal material for peripheral arterial reconstruction and coronary artery revascularization. We describe a new endoscopic technique of saphenous vein harvest in infrainguinal arterial bypass surgery. Methods: A retrospective analysis of 64 infrainguinal bypass procedures was performed comparing the standard open technique of saphenous vein harvesting with a new less invasive endoscopic technique. Results: There were no differences in age, gender, indications for surgery, or proximal or distal anastomosis between the two groups. There were also no significant differences in early wound complications, early patency, and transfusion requirements. In the endoscopic group, length of operation was longer (189 versus 158 minutes; P

Background It has been demonstrated that surgeons and surgery residents, trained in the focused abdominal sonographic examination, are able to accurately and reliably evaluate trauma patients. Despite this, radiologists have objected to surgeon-performed sonography for several reasons. We set out to compare the accuracy of sonographic examinations performed by surgery residents and radiologists. Methods A retrospective review of medical records of all trauma patients who received focused ultrasound examinations from January 1, 1995, through June 30, 1996, at one of two American College of Surgeons-verified Level I trauma centers in the same city was undertaken. Ultrasound examinations were performed by surgery residents at trauma center A (TCA) and by radiologists or radiology residents at trauma center B (TCB). Findings for each patient were compared with the results of computed tomography, diagnostic peritoneal lavage, operative exploration, or observation. Sensitivity, specificity, accuracy, positive predictive value, and negative predictive value were calculated for each group of patients. Comparison of patient charges for the trauma ultrasound examinations at each of the trauma centers was also made. Results Patient populations at the two centers were similar except that the mean Injury Severity Score at TCB was higher than at TCA (11.74 vs. 9.6). Sensitivity, specificity, accuracy, or negative predictive value were not significantly different between the two cohorts. A significantly lower positive predictive value for examinations performed by surgery residents was noted and attributed to a lower threshold of the surgery residents to confirm their findings by computed tomography. Billing data revealed that the average charge for trauma sonography by radiologists (TCB) was $406.30. At TCA, trauma sonography did not generate a specific charge; however, a $20.00 sum was added to the trauma activation fee to cover ultrasound machine maintenance and supplies. Conclusion Focused ultrasound examination in the trauma suite can be as safely and accurately performed by surgery residents as by radiologists and radiology residents and should be a routine part of the initial trauma evaluation process.

BACKGROUND: Motor vehicle collisions (MVCs) are the second leading cause of injury among octogenarians. Physicians and families lack outcomes-based data to assist in the decision-making process concerning injury treatment in this population. The purpose of this study was to evaluate 1-year postdischarge mortality in octogenarian MVC patients, cause of death, and patterns predictive of mortality. METHODS: A 10-year retrospective review was conducted of trauma patients 80 years and older who were involved in an MVC and were subsequently discharged alive. Data collected included demographics, injury severity and patterns, hospitalization details, and outcomes. State death database and hospital records were queried to determine cause of death for patients who died within 12 months of hospital discharge. Analyses were conducted to explore if a relationship existed between severity of injury and injury patterns to 12-month postdischarge mortality. RESULTS: Among the 199 patients included in this study, mean (SD) age and Injury Severity Score (ISS) was 84.2 (3.3) years and 9.3 (8.2), respectively. Twenty-two patients (11.1%) died within 12 months. Among these patients, cause of death was directly related to trauma in nine (40.9%), likely related to trauma in seven (31.8%), and unrelated to trauma in six (27.3%). More severely injured patients (ISS >15, p = 0.0041) and those admitted to the intensive care unit (ICU) (p = 0.0051) were more likely to die within 12 months of discharge. Results indicated a trend toward higher mortality in patients with pneumonia. Rib, hip, and pelvic fractures; spinal injuries; intubation upon hospital arrival; and need for mechanical ventilation were not associated with higher postdischarge mortality rates. CONCLUSION: The commonly held belief that the majority of octogenarians with MVC-related trauma die within 1 year of hospital discharge is refuted by this study. Only injury severity, ICU admission, and ICU duration were predictive of mortality within 12 months following discharge. LEVEL OF EVIDENCE: Prognostic study, level III. Language: en

Background While percutaneous tracheostomy (PT) is becoming the procedure of choice for elective tracheostomy, there is little late complication data. This study compared incidence of, and factors contributing to, tracheal stenosis following PT or open tracheostomy (OT). Methods A 10-year review was conducted of trauma patients undergoing tracheostomy. Data on demographics, injury severity, tracheostomy type, complications, and outcomes were compared between patients receiving PT or OT and for those with or without tracheal stenosis. Results Of 616 patients, 265 underwent OT and 351 underwent PT. Median injury severity score was higher for PT (26 vs 24, P = .010). Overall complication rate was not different (PT = 2.3% vs OT = 2.6%, P = .773). There were 9 tracheal stenosis, 4 (1.1%) from the PT group and 5 (1.9%) from the OT group ( P = .509). Mortality was higher in OT patients (15.5% vs 9.7%, P = .030). Patients developing tracheal stenosis were younger (29.8 vs 45.2 years, P = .021) and had a longer intensive care unit length of stay (28.3 vs 18.9 days, P = .036). Conclusion Risk of tracheal stenosis should not impact the decision to perform an OT or PT.

Background : A gradual change in the management of splenic injuries has occurred at our institution. This study was therefore undertaken to determine whether changes in management of splenic injury influenced outcomes during the past 30 years. Patients and methods : A retrospective study of patients admitted with splenic trauma between 1965 and 1994 was performed. Two hundred seven patients were identified and demographic and outcome data were recorded. Patients were then grouped based upon the period in which they received treatment (ie, Period I [1965 to 1974], Period II [1975 to 1984], and Period III [1985 to 1994]) and the type of treatment received (ie, splenectomy, splenorrhaphy, or observation). Results : More patients were treated in Period III than in the other two periods, and Period III patients had shorter hospital stays. Splenectomy was solely used during Period I; splenorrhaphy and observation were occasionally performed during Period II; and splenectomy, splenorrhaphy, and observation were performed in near-equal numbers during Period III. Mortality was similar for each period, though Injury Severity Scores (ISS) were higher during later years. When compared by treatment modality, patients receiving splenectomy had higher ISS and splenic injury classifications. Conclusion : Patients treated by splenorrhaphy and observation for splenic injury have markedly increased over the past 30 years without adverse outcome.

The study first assessed comfort levels of physical and occupational therapists who provide burn care prior to a hands-on intervention, then assessed therapists' confidence levels following an educational intervention. Physical and occupational therapists who previously treated burn survivors were invited to complete a preworkshop confidence level survey. From this information, four burn rehabilitation interventional categories were identified: positioning and exercise, compression, wound healing, and burn resources. A one-day workshop was held targeting these categories. Surveys were offered at the conclusion of the workshop as well as at 6-month follow-up. Initial survey results (n = 31) indicated that more than 75% of therapists felt unconfident or strongly unconfident in providing burn rehabilitation to patients. The postworkshop survey demonstrated significant improvements in all interventional categories. Further analysis revealed that baseline confidence levels for positioning and exercise were significantly higher than the other categories (P < .03). Six-month follow-up results (n = 20) confirmed that confidence gained from the workshop remained significantly higher than preworkshop confidence levels. Baseline therapists' confidence levels in treating burn survivors were low, but improved following a one-day educational workshop. Providing hands-on burn education improved the confidence of therapists who treat burn survivors. Future efforts to improve therapist confidence and patient outcomes need to be explored.

Traumatic brain injury remains one of the most prevalent and costly injuries encountered within the discipline of trauma and represents a leading cause of morbidity and mortality within our society. The purpose of this study was to compare the safety of intracranial pressure (ICP) monitor placement by general surgery residents and neurosurgeons.A retrospective chart review of all trauma patients requiring ICP monitor placement at an American College of Surgeons-verified Level 1 trauma center during a 10-year period was performed. Comparison of demographic variables, injury severity, intracranial injuries, incidence of ICP monitor-related complications, and outcomes were made between general surgery residents, trauma surgeons, and neurosurgeons.There were 546 patients included in the study. The average age of the cohort was 37.6 years, with an average hospital length of stay being 16.0 days and an Injury Severity Score of 27.7. Mechanisms of injury varied, but 58.8% was a result of motor vehicle and motorcycle collisions, and an additional 19.2% was a result of falls. No significant difference was found in terms of procedure-related complications between subgroups, including intracranial hemorrhage, infection, malfunctions, dislodgment, or death.Our results demonstrate that the placement of ICP monitors may be performed safely by both neurosurgeons and non-neurosurgeons. This procedure should thus be considered a core skill for trauma surgeons and surgical residents alike, thereby allowing initiation of prompt medical treatment in both rural areas and trauma centers with inadequate neurosurgeon or fellow coverage.Therapeutic study, level IV.

Background Topical anesthetics have been used in various procedures. The purpose of this study was to evaluate efficacy of lidocaine/prilocaine cream in decreasing the pain of injection for sentinel lymph node biopsy. Methods A prospective, randomized, placebo-controlled study was conducted on female breast cancer patients undergoing periareolar injection for sentinel lymph node isolation. Subjects applied lidocaine/prilocaine cream or a placebo cream before injection and completed a survey postoperatively. Results Twenty treatment and 19 control patients were studied. There was a trend for control subjects to indicate that the injection was “painful” or “extremely painful” more often than treatment subjects (52.6% vs 25.0%, respectively, P = .074). The treatment group was more likely to recommend the cream to other cancer patients (70.0% vs 42.1%), with a trend toward significance (P = .076). Conclusions This study showed no statistically significant reduction in pain scores in subjects receiving the topical anesthetic. Further studies targeting patients with low pain tolerance may prove more effective.

Background This study was conducted to evaluate the change in the treatment plan observed when clinical decisions are made based on initial carotid duplex ultrasonography (DU) performed at an outside center before surgical consultation versus those made based on DU performed in a dedicated vascular laboratory. Methods A prospective study of patients who underwent initial DU at an outside facility and repeat DU in a dedicated vascular laboratory for evaluation of carotid stenosis was performed. Initial DU was compared with repeat DU to evaluate clinical impact. Results Ninety-six consecutive patients were evaluated. Disagreement between initial DU and repeat DU was observed in 27.1% of patients. This disagreement led to a change of treatment plan in 23 of 146 (15.8%) carotid arteries studied. Conclusions Reliance on 1 DU in clinical practice, when performed outside a dedicated vascular laboratory, may lead to both unnecessary surgery and missed opportunities for surgery to prevent stroke.

To determine the effect of the 80-hour work week restrictions on general surgery resident operative volume in a large, community-based, university-affiliated, general surgery residency program.We performed a retrospective review of Accreditation Council for Graduate Medical Education (ACGME) operative logs of general surgery residents graduating from a single residency. The control group consisted of the residents graduating in the 3 years prior to the work-hour restriction implementation (2001, 2002, and 2003). Our comparison group consisted of those residents graduating in the first 2 classes whose entire residency was conducted after the implementation of the 80-hour work week (2008 and 2009). Comparisons were made between the control and the comparison groups in the 19 ACGME defined categories, total number of major cases, total number of chief cases, and total number of teaching assist cases.Operative volumes in 13 categories (skin/soft tissue/breast, alimentary tract, abdominal, liver, pancreas, vascular, endocrine, pediatrics, endoscopy, laparoscopic-complex, total chief cases, total major cases, and teaching cases) were not significantly affected by the implementation of the 80-hour work week. One of the 19 categories (laparoscopic-basic) showed a significant increase in operative volume (p0.0001). In 4 of the 19 categories (head/neck, operative-trauma, thoracic, and plastics), operative volume was significantly decreased in the post-80-hour work week era (p0.05). Nonoperative trauma could not be assessed, as the category did not exist before the work-hour restrictions.Resident operative volume at our institution's general surgery residency program largely has been unaffected by implementation of the 80-hour work week. Residencies in general surgery can be structured in a manner to allow for compliance with duty-hour regulations while maintaining the required operative volume outlined by the ACGME defined categories.

BACKGROUND: Previous assessments linked transfusions in trauma to increased respiratory and infectious complications. However, these studies included patients with severe trauma, brisk hemorrhage, and shock. Thus, the potentially harmful impact of transfusion was difficult to determine. METHODS: A retrospective review of all trauma patients with an injury severity score (ISS) of 9 to 14 admitted to a Level 1 Trauma Center over a 5-year period was performed. Patients were stratified by transfusion history and injury severity. RESULTS: Records of 2,332 patients were reviewed; 208 (8.9%) received at least 1 packed red blood cell transfusion. The incidence of complications was significantly higher in patients receiving transfusions (42.3% vs 9.0%; P < .001), and transfusion was a significant independent predictor of the development of a complication (odds ratio, 5.85; P < .001). Further, the association of transfusion with complications was dose-dependent. Transfusion was associated with a significantly increased hospital length of stay (10.6 vs 3.9 days; P < .0001). CONCLUSIONS: Moderately injured trauma patients receiving transfusions suffered significantly more complications. Indications for transfusion in this population should be reassessed carefully.

Background Recombinant factor VIIa (rFVIIa) frequently is used for treatment of life-threatening hemorrhage in trauma. Methods A retrospective review of injured patients receiving rFVIIa at an American College of Surgeons–verified Level 1 trauma center was performed. Controls were matched for age, sex, Injury Severity Score, and traumatic brain injury. Thrombotic complications in patients administered rFVIIa, including deep venous thrombosis (DVT), pulmonary embolus, acute myocardial infarction, ischemic stroke, mesenteric ischemia, arterial thromboembolism, and death, were determined. Results Thirty-six patients were given rFVIIa, of whom 5 (13.8%) had thrombotic complications. Indications for rFVIIa were life-threatening intracranial bleeding in the presence of pre-injury anticoagulation or hemorrhage. The incidences of DVT (n = 4) and acute myocardial infarction (n = 1) were noted. In the control group, there were fewer thrombotic complications (DVT, 1; pulmonary embolus, 1). The mortality rate (52.8%) was higher in patients receiving rFVIIa compared with the control group (22.2%; P = .014). Pre-injury anticoagulation was common in the treatment group. Conclusions Pre-injury anticoagulation is frequently the indication for rFVIIa administration. Thrombotic complications occur with rFVIIa administration. The mortality rate of injured patients who receive rFVIIa is high.

The purpose of this study was to compare flexion and extension (F/E) cervical radiographs with CT of the cervical spine in patients sustaining blunt trauma for the evaluation of ligamentous injury. A retrospective chart review of 2 years duration at an American College of Surgeons-verified Level I trauma center was performed. All patients sustaining blunt trauma who were evaluated with both a CT as well as F/E radiographs were identified. Exclusion criteria included penetrating injuries, neurologic symptoms, and age younger than 18 years. Follow-up MRI of each positive F/E radiograph after a negative CT scan was performed. Flexion and extension cervical radiographs were obtained in 379 patients after CT. Eight positive F/E radiographs were obtained after a negative CT scan. Follow-up MRI was negative for ligamentous injury in all cases. No cases of a clinically relevant positive F/E radiograph after a negative CT scan were identified. Follow-up F/E radiographs are not efficacious when a negative CT has been performed in blunt trauma without neurologic findings.

As physicians increasingly use magnetic resonance imaging (MRI) for the evaluation of newly diagnosed breast cancers, a review of the correlation between MRI and pathology tumor size is imperative.A retrospective review of 91 breast tumors comparing preoperative MRI tumor size to final pathology tumor size was performed.MRI and pathology tumor size were positively correlated (R = .650), but with an average overestimation by MRI of .63 cm (P.0001). When stratified by MRI tumor size (or = 2.0 cm and2.0 cm), a significant difference was found only in tumors greater than 2.0 cm (average overestimation = 1.06 cm; P.0001). This trend continued for the histological subtypes of ductal carcinoma in situ (DCIS), invasive ductal carcinoma (IDC), and invasive lobular carcinoma (ILC).MRI tumor size correlates with pathology size; however, a significant overestimation exists, particularly for tumors2.0 cm. Clinicians should therefore use caution in relying on MRI tumor size in determining candidacy for breast conservation therapy (BCT).