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Delayed gastrointestinal (GI) recovery remains a significant morbidity after colorectal surgery. Intracorporeal anastomosis for right colectomy may hasten GI recovery. Therefore, the objective of this study was to determine the effect of intracorporeal versus extracorporeal anastomosis on GI recovery after elective laparoscopic right colectomy within an established ERAS program. Adult patients undergoing elective laparoscopic right colectomy at a single high-volume institution from 07/2014 to 12/2018 were reviewed. Patients were divided into two groups: intracorporeal (IC) and extracorporeal (EC). The primary outcome was time to GI-3 defined as days to tolerance of solid diet and first flatus/bowel movement. Prolonged postoperative ileus (PPOI) was defined as GI-3 not met by postoperative day 4. Secondary outcomes were length of stay (LOS) and overall 30-day complications. Sensitivity analysis was performed using coarsened exact matching to account for unmeasured confounding. Multiple regression was performed using a Cox proportional hazard model to identify predictors of GI recovery. A total of 346 patients were reviewed, of which 226 were included (71IC, 155EC). Patient characteristics were well balanced between groups: mean age was 64.9 years (SD 15.9), BMI was 26.3 (SD 5.7), 38.1% of patients had ASA ≥ 3, and 78.3% underwent surgery for neoplasms. IC anastomosis was associated with longer operative duration (165 min (SD 40); 144 min (SD 48), p = 0.002). There was no difference in the median time to GI-3 (IC 2 days [IQR1-2]; EC 2 days [IQR2-3], p = 0.135). The incidence of PPOI (IC 8.5%; EC 10.3%, p = 0.659), superficial SSI (4.2% vs. 5.8%, p = 0.757), deep SSI (2.8% vs. 5.2%, p = 0.729), and median LOS (3 days [IQR 2–4] vs. 3 [IQR 3–5], p = 0.059) were also similar. On multivariate analysis, IC anastomosis did not independently predict faster GI recovery (HR 0.98, 95% CI 0.71–1.34). Similar results were observed in the matched cohort (185 patients (61IC, 124EC)). In this study, IC anastomosis was not associated with faster GI recovery or reduced complication rate compared to EC anastomosis. Longer term studies may be required to determine the potential benefits of IC anastomosis.

Laparoscopic gastric plication (LGCP) is a relatively new bariatric-metabolic operation. The greater gastric curvature is invaginated into the gastric lumen, resulting in a shape similar to that obtained after sleeve gastrectomy. In our paper, we report two interesting cases of patients with gastric plication who presented specific findings - food bezoar and gastric diverticulum. Case reports of bezoars after bariatric surgery are reported most commonly after gastric banding and gastric bypass surgery. Diverticulum of the gastric wall is a complication specific to LGCP when a part of the invaginated gastric wall is slipped between two sutures. A prompt endoscopic intervention is recommended to relieve the obstruction and, in case of diverticulum, to diagnose and manage it surgically.

Over 6.5 million women in the United States suffer from female stress urinary incontinence (SUI). Only ~200,000 women choose surgery. There may be a role for a non-surgical, minimally invasive procedure that provides thermal shrinkage/remodeling of submucosal collagen in the endopelvic fascia. This study describes design, characterization, and preliminary testing of a novel probe with integrated contact cooling for potential use in transvaginal laser treatment of SUI. Laser energy at a deeply penetrating, near-infrared wavelength of 1075 nm was delivered through a 600-μm-core fiber optic patchcord into a 90° side-firing probe head (19 × 22 mm) with integrated flow cell and sapphire window cooled to −2°C by circulating an alcohol-based solution. An inflatable balloon attached to the probe insured contact with vaginal wall. A force sensor and thermocouples monitored pressure and temperature. Thermal lesions were created in vaginal tissue of three cadavers (power = 4.6–6.4 W; spot diameter = 5.2 mm; time = 30 s). Thermal lesion areas measured 3.1–4.6 mm(2), while preserving the vaginal wall to a depth of 0.8–1.1 mm. Consistent tissue contact and cooling was maintained using the force sensors. Preliminary cadaver studies demonstrated subsurface treatment of endopelvic fascia with partial preservation of the vaginal wall. Future studies will optimize parameters for thermal remodeling with further tissue surface preservation.

Dual pulse mode has recently been integrated into Holmium:YAG laser systems to reduce stone retropulsion. This study explores similar pulse shaping approaches with Thulium fiber laser (TFL). A TFL at 1940 nm wavelength produced three temporal pulse profiles: (1) square pulse, (2) dual pulse, with low energy initial pulse followed by higher energy second pulse, and (3) ascending staircase pulse shape. Energies of 0.1 - 2.0 J, pulse rates of 5 - 200 Hz, average power of 10 and 20 W, and laser irradiation time of 5 s were used (n=5 per group). Stone phantoms (6-mmdiameter, 200-mg-mass) were placed on a horizontal, v-shaped trough, submerged in water, and then irradiated with TFL using a 200-μm-core optical fiber. Dual pulse stone displacements using pulse energies of 0.1, 0.2, 0.5, 1.0, and 2.0 J, measured 65%, 75%, 100%, 100%, and 110% of square pulse displacement at 10 W, and 65%, 60%, 60%, 90%, and 105% of square pulse displacement at 20 W. Staircase pulse stone displacements measured ~ 85% of square pulse stone displacement at 1.0 and 2.0 J for both 10 and 20 W. At lower energies (0.1 - 0.5 J), staircase profile produced a suction effect, resulting in the stone being pulled back to the fiber. Dual pulse mode only reduced stone retropulsion at lower energy settings, possibly due to excessive energy in initial pulse at higher settings. Low power (10 W) square, dual, and staircase pulse shapes ablated uric acid stones at rates of 1.7 ± 0.4, 1.9 ± 0.5, and 1.7 ± 0.5 mg/s, respectively. High power (20 W) square, dual, and staircase pulse shapes ablated stones at a rate of 2.6 ± 0.6, 3.0 ± 0.4, and 2.7 ± 0.7 mg/s, respectively. Future studies will utilize optical imaging of vapor bubble formation as a function of temporal pulse profile to optimize laser parameters for reducing stone retropulsion and enhancing TFL stone ablation rates.

The experimental Thulium fiber laser (TFL) is currently being explored as an alternative to the gold standard Holmium:YAG laser for lithotripsy. The TFL emits laser radiation at two primary wavelengths, 1908 or 1940 nm, which closely match high and low temperature water absorption peaks in tissue, respectively. Water is a primary absorber of infrared laser radiation, and is present in the pores of kidney stones in the urinary tract. Constant saline irrigation is also applied through the ureteroscope working channel to clear stone debris and improve visibility and safety during lithotripsy. Previous studies have shown that the water absorption peak shifts from 1940 nm to 1920 nm, as water temperature increases heating. At high water temperatures, the absorption coefficient (μa) is ~ 150 cm-1 at 1908 nm and ~ 135 cm-1 at 1940 nm. The goal of this study was to determine whether this 10% difference translates into a measurable difference in kidney stone ablation rates. Two Thulium fiber lasers (1908 and 1940 nm) were tested at similar laser parameters of 35 mJ energy per pulse, 500 μs pulse duration, 300 Hz pulse rate, and 10.5 W average power, with energy delivered through 200-μm-core optical fibers. The handheld fiber was maintained in contact with 6-9 mm diameter uric acid (UA) stones, immersed in a saline bath with saline flow (n=10 stones per group). Time to fragment and pass all stone fragments through a 1 mm sieve was measured, and then divided into initial stone mass to calculate ablation rate. For each laser group, 1908 and 1940 nm, initial stone mass was 270 ± 60 mg vs. 260 ± 50 mg, respectively (p = 0.9). Stone ablation rates measured 0.9 ± 0.2 and 0.9 ± 0.1 mg/s, respectively (p = 0.9). Stone ablation thresholds also measured 8 ± 7 and 5 ± 13 J/cm2, respectively (p = 0.8). There was no significant difference in UA stone ablation thresholds and ablation rates between 1908 and 1940 nm TFL wavelengths.

Laser lithotripsy depends in part on fragmenting stones to sufficiently small size for spontaneous passage or extracting all large residual stone fragments to provide high stone free success rates, so a second repeat procedure is unnecessary. This preliminary study describes initial development of an optical system and software capable of tracking and labeling kidney stones. Machine learning and image processing techniques were implemented to track, label, and size, on a relative scale, stone fragments. Thresholds were placed on minimum stone fragment size (based on pixel sizes). For system validation, a series of still images from the laboratory setup and previously recorded clinical lithotripsy procedures were analyzed. A laboratory test was also conducted with homogenous background and video to determine number of true positives, false positives, and false negatives. In still images, 8/8 (100%) stones in the laboratory setup and 4/4 (100%) stones in clinical lithotripsy videos were correctly identified. A separate laboratory study correctly identified all five stones in each frame across a total of 110 video frames (550/550) (100%) with a total of 49/550 false positives (9%) and 0/550 (0%) false negatives, at a maximum frame rate of 50 Hz. This preliminary stone tracking study correctly identified stone fragments in laboratory frames for still and motion video and during still images from clinical lithotripsy procedures and experimental settings. Further development of software and optical tracking system is planned.

Recent advances in Holmium and Thulium fiber lasers (TFL) enable operation at similar parameters for comparison. A ‘dusting’ lithotripsy mode with low energy per pulse (0.2-0.4 J) and high pulse rates (50-80 Hz), is preferred to produce smaller residual stone fragments for natural passage through the urinary tract. Holmium and TFL were compared for dusting using three groups, G1: 0.2 J/50 Hz/10 W; G2: 0.2 J/80 Hz/16 W; and G3: 0.4 J/80 Hz/32 W. A setup with 1 x 1 cm cuvette and 1.0 mm sieve was used with total laser operation time limited to ≤ 5 min. Calcium oxalate monohydrate (COM) stones with average initial stone mass of 216-297 mg between groups were used. Holmium ablation rates were lower than for TFL at all settings (G1: 0.3 ± 0.2 vs. 0.8 ± 0.2; G2: 0.6 ± 0.1 vs. 1.0 ± 0.4; G3: 0.7 ± 0.2 vs. 1.3 ± 0.9 mg/s). TFL also produced a greater percentage by mass of stone dust (< 0.5 mm) than Holmium. For all three settings, 1/15 (7%) stones treated with Holmium were fragmented in ≤ 5 min vs. 9/15 (60%) stones treated with TFL. These preliminary studies demonstrate that TFL is a viable laser for stone dusting, producing higher stone ablation rates and smaller stone fragments than Holmium laser.

This preliminary study investigates an automated, vibrating fiber tip for dusting of kidney stones during Thulium fiber laser (TFL) lithotripsy. A (0.75-mm-diameter, 5-mm-length) magnetic bead was attached to the fiber jacket 2 cm from distal fiber tip, and a solenoid made of ferrite material was used to create a magnetic force on the bead, inducing fiber vibration. Calibration tests for fiber motion in both air and water were performed. Uric acid (UA) stones were ablated using 50-, 100-, and 150-μm-core fibers, and ablation crater characteristics (surface area, volume, depth, and major/minor axis) were measured using optical coherence tomography after delivery of 1500 TFL pulses at 1908 nm, 33 mJ, 500 μs, and 300 Hz. The resonant frequency was dependent on fiber diameter and rigidity, with a cutoff pivot point for optimum motion of 3 to 4 cm. Maximum fiber displacement was about 1 mm in water and 3.5 mm in air. For all fiber diameters tested, ablated surface area was two times greater with vibrating fiber. Similar ablation volume was removed with vibrating and fixed fibers, consistent with previous literature reporting similar ablation rates independent of fiber diameter, given a fixed energy per pulse. This preliminary study demonstrated functionality of an automated, vibrating fiber system for stone “dusting”, with two times larger surface area but equivalent ablation volumes as a fixed fiber. Continued development of this method is warranted, with emphasis on optimization of fiber parameters (especially displacement) and miniaturization of components for future integration into ureteroscopes.

Previous Thulium fiber laser (TFL) studies using fiber optic muzzle brake tips reported reduced stone retropulsion and distal fiber tip degradation. This study compares muzzle brake tips of various dimensions using the TFL at 1908 and 1940 nm wavelengths in terms of stone phantom retropulsion displacement using a pendulum setup, needle hydrophone pressure transient measurements, and uric acid (UA) stone ablation rates. Low and high TFL pulse energies of 35 and 140 mJ, 500 μs pulse duration, and pulse rates up to 300 Hz were used with 100- and 200-μm-core optical fibers. “Small”, “medium”, and “large” muzzle brake tips dimensions measured 180/340, 360/560, and 550/710 μm inner/outer diameter, respectively, with a porthole positioned 500 μm from distal muzzle brake end. Pendulum displacement measured 50%, 200%, and 50% of bare trunk fibers for small, medium and large muzzle tips, respectively, in optimal configuration. Needle hydrophone pressures measured 300%, 20%, and 50% of bare trunk fiber for small, medium and large muzzle tips, respectively, in optimal configuration. Stone ablation rates at low pulse energy (35 mJ) were maintained for medium muzzle brake tips while small and large muzzle brake tips performed about 10 and 7.5 times worse than bare fibers. At high pulse energy (140 mJ), the large muzzle tip performed similar to a bare 200-μm-core fiber with 100%, 50%, and 100% the displacement, pressure, and ablation rate. These studies show feasibility of modifying muzzle brake tip dimensions to obtain comparative ablation rates and minimal stone retropulsion for lithotripsy.

Background Fundoplication is performed routinely during laparoscopic repairs of a paraesophageal hernia, but the degree of fundoplication remains controversial. The purpose of this study is to assess postoperative dysphagia and reflux after a Dor versus a Nissen fundoplication in patients undergoing laparoscopic repair of giant paraesophageal hernias. Methods We performed a retrospective cohort study of all patients undergoing laparoscopic repair of giant paraesophageal hernias with Nissen or Dor fundoplication between January 2012 and December 2017 at a high-volume center, excluding revisional and emergency cases. Primary outcomes were reflux and dysphagia at 1 and 6 months. Severe dysphagia was defined as intolerance to liquids. Balanced cohorts were created using coarsened exact matching. Results A total of 106 patients were included, and 87 were matched (Dor = 48, Nissen = 58). Baseline characteristics were well balanced between matched groups. Mean follow-up duration was 17.7 months (standard deviation 16.4). The incidence of severe dysphagia at 1 month was less in the Dor group (0 of 48 vs 8 of 58, P = .02) with similar reflux symptoms. There was no difference in severe dysphagia and reflux symptoms at 6 months and at the latest visit. Conclusion Dor fundoplication is associated with less severe, early postoperative dysphagia. Future studies assessing the relative importance of dysphagia and reflux on quality of life should be conducted to tailor the operative technique and optimize patient satisfaction.

This statement presents my views on buybacks and my general reactions to provisions in four pieces of legislation relating to stock buybacks. Part I describes the role of stock buybacks in the economy and offers some “investor-benign” explanations for firms’ use of repurchases rather than dividends to distribute cash to investors. Part I then explains that the overall level of shareholder payouts (that is, the total amount of dividends and repurchases) does not appear to be too high; in fact, it may well be too low. Part II describes the current regulation of buybacks, which I believe is too lax and enables their abuse by corporate executives. In particular, I will explain how current regulation can enable executives to use buybacks to enrich themselves at the expense of public investors, through (1) indirect insider trading, (2) the manipulation of the stock price and EPS metrics in compensation arrangements, and (3) “false signaling:” announcing repurchases that executives do not intend to carry out, solely to boost the stock price before executives unload shares. Part III suggests a disclosure rule that would reduce executives’ ability to engage in the above-mentioned abuses, and therefore, better protect public investors: requiring public firms (like their insiders) to disclose trades in firm stock within two business days. I also describe additional measures that could be taken if this disclosure rule turns out be insufficient. Part IV offers initial reactions to key provisions in these four pieces of legislation.

Introduction: The principles of PEH repair involve primary closure of the hiatus around the esophagus after complete reduction of the hernia sac. However, this repair is associated with a high failure rate, leading surgeons to consider prosthetic materials to reinforce the hiatal closure. In this chapter, we review the literature comparing outcomes of hiatal mesh reinforcement to simple closure during laparoscopic PEH repair.

Introduction Infrared (IR) lasers are being explored as an alternative to radiofrequency (RF) and ultrasonic (US) devices for rapid hemostasis with minimal collateral zones of thermal damage and tissue necrosis. Previously, a 1,470 nm IR laser sealed and cut ex vivo porcine renal arteries of 1–8 mm diameter in 2 seconds, yielding burst pressures greater than 1,200 mmHg and thermal coagulation zones less than 3 mm. This preliminary study describes in vivo testing of a handheld laser probe in a porcine model. Methods A handheld prototype with vessel/tissue clasping mechanism was tested on 73 blood vessels less than 6 mm diameter using 1,470 nm laser power of 35 W for 1–5 seconds. Device power settings, irradiation time, tissue type, vessel diameter, and histology sample number were recorded for each procedure. The probe was evaluated for hemostasis after sealing isolated and bundled arteriole/venous (A/V) vasculature of porcine abdomen and hind leg. Sealed vessel samples were collected for histological analysis of lateral thermal damage. Results Hemostasis was achieved in 57 of 73 seals (78%). The probe consistently sealed vasculature in small bowel mesentery, mesometrium, and gastrosplenic and epiploic regions. Seal performance was less consistent on hind leg vasculature including saphenous arteries/bundles and femoral and iliac arteries. Collagen denaturation averaged 1.6 ± 0.9 mm in eight samples excised for histologic examination. Conclusions A handheld laser probe sealed porcine vessels, in vivo. Further probe development and laser parameter optimization is necessary before infrared lasers may be evaluated as an alternative to RF and US vessel sealing devices. Lasers Surg. Med. © 2016 Wiley Periodicals, Inc.

We conducted a randomized trial comparing minilaparoscopic cholecystectomy (MLC) to conventional laparoscopic cholecystectomy (CLC) to determine whether MLC accelerated recovery of physical activity after elective surgery (NCT01397565). A total of 115 patients scheduled for elective cholecystectomy were randomized to either CLC or MLC. Both procedures used a 10-mm umbilical port, but the three upper abdominal ports were 5 mm in CLC and 3 mm in MLC. Primary outcome was self-reported physical activity 1 month after surgery as estimated by Community Health Activities Model Program for Seniors questionnaire (kcal/kg/week). Secondary outcomes were umbilical pain, abdominal pain, nausea and fatigue (VAS, 1–10), and cosmetic result at one and 3 months. Patients received identical surgical dressings for 1 week, and assessors were blinded to group allocation. Forty-two patients randomized to CLC group and 33 patients randomized to MLC remained in the trial and were analyzed. Both groups were similar at baseline characteristics. In the MLC group, at least one 5-mm port was used in 17 (51.5 %) mainly due to unavailability of ML equipment. Median (IQR) physical activity for the CLC and MLC groups was similar at baseline (23.4 [13.1, 44.6] vs 23.6 [14.2, 66.9] kcal/kg/week, p = 0.35) and at 1 month (20 [7.9, 52.5] vs 16.8 [11.8, 28.6] kcal/kg/week, p = 0.90). One month post-op, umbilical pain and abdominal pain were similar, but the CLC group reported higher fatigue (4 [1–5] vs 1 [0–4], p = 0.05) and worse scar appearance scores (4 [3, 4] vs 4.5 [4, 5], p = 0.009). At 3 months, the CLC group had worse scar appearance (4 [3–5] vs 5 [4–5], p = 0.02) and lower scar satisfaction scores (4 [3, 4] vs 4 [3.5–4], p = 0.04). Recovery of physical activity was similar after MLC and CLC. MLC resulted in less fatigue and better scar appearance and satisfaction. These benefits were seen despite the need to upsize one or more ports in more than half of patients related to availability of the miniature instruments.

Errors in judgment during laparoscopic cholecystectomy can lead to bile duct injuries and other complications. Despite correlations between outcomes, expertise and advanced cognitive skills, current methods to evaluate these skills remain subjective, rater- and situation-dependent and non-systematic. The purpose of this study was to develop objective metrics using a Web-based platform and to obtain validity evidence for their assessment of decision-making during laparoscopic cholecystectomy. An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from six institutions completed a 12-item assessment, developed based on a cognitive task analysis. Five items required subjects to draw their answer on the surgical field, and accuracy scores were calculated based on an algorithm derived from experts’ responses (“visual concordance test”, VCT). Test–retest reliability, internal consistency, and correlation with self-reported experience, Global Operative Assessment of Laparoscopic Skills (GOALS) score and Objective Performance Rating Scale (OPRS) score were calculated. Questionnaires were administered to evaluate the platform’s usability, feasibility and educational value. Thirty-nine subjects (17 surgeons, 22 trainees) participated. There was high test–retest reliability (intraclass correlation coefficient = 0.95; n = 10) and internal consistency (Cronbach’s α = 0.87). The assessment demonstrated significant differences between novices, intermediates and experts in total score (p

Guidelines recommend biologic prosthetics for ventral hernia repair (VHR) in contaminated fields, yet long-term and patient-reported data are limited. We aimed to determine the long-term rate of hernia recurrence, and other clinical and patient-reported outcomes following the use of porcine small intestine submucosa (PSIS) for VHR in a contaminated field. Consecutive patients undergoing open VHR with PSIS mesh in a contaminated field from 2004 to 2014 were prospectively evaluated for hernia recurrence and other post-operative complications. Multivariate logistic and Cox regression analyses identified predictors of hernia recurrence and surgical site infection. Patient-reported outcomes were evaluated using SF-36, Hernia-Related Quality-of-Life Survey (HerQLes) and Body Image Questionnaire instruments. Forty-six hernias were repaired in clean-contaminated [16 (35 %)], contaminated [11 (24 %)] and dirty [19 (41 %)] fields. Median follow-up was 47 months [interquartile range: 31–79] and all patients had greater than 12-month follow-up. Sixteen patients (35 %) were not re-examined. Incidence of surgical site events and surgical site infection were 43 % (n = 20) and 56 % (n = 25), respectively. American Society of Anesthesiologists score 3 or greater was an independent predictor of surgical site infection (odds ratio 5.34 [95 % confidence interval 1.01–41.80], p = 0.04). Hernia recurrence occurred in 61 % (n = 28) with a median time to diagnosis of 16 months [interquartile range 8–26]. After bridged repair, 16 of 18 patients (89 %) recurred, compared to 12 of 28 (43 %) when fascia was approximated (p

Background and Objectives A non-surgical method is being developed for treating female stress urinary incontinence by laser thermal remodeling of subsurface tissues with applied surface tissue cooling. Computer simulations of light transport, heat transfer, and thermal damage in tissue were performed, comparing transvaginal and transurethral approaches. Study Design/Materials and Methods Monte Carlo (MC) simulations provided spatial distributions of absorbed photons in the tissue layers (vaginal wall, endopelvic fascia, and urethral wall). Optical properties (n,μa,μs,g) were assigned to each tissue at λ = 1064 nm. A 5-mm-diameter laser beam and incident power of 5 W for 15 seconds was used, based on previous experiments. MC output was converted into absorbed energy, serving as input for finite element heat transfer simulations of tissue temperatures over time. Convective heat transfer was simulated with contact probe cooling temperature set at 0°C. Variables used for thermal simulations (κ,c,ρ) were assigned to each tissue layer. MATLAB code was used for Arrhenius integral thermal damage calculations. A temperature matrix was constructed from ANSYS output, and finite sum was incorporated to approximate Arrhenius integral calculations. Tissue damage properties (Ea,A) were used to compute Arrhenius sums. Results For the transvaginal approach, 37% of energy was absorbed in the endopelvic fascia target layer with 0.8% deposited beyond it. Peak temperature was 71°C, the treatment zone was 0.8-mm-diameter, and 2.4 mm of the 2.7-mm-thick vaginal wall was preserved. For transurethral approach, 18% energy was absorbed in endopelvic fascia with 0.3% deposited beyond the layer. Peak temperature was 80°C, treatment zone was 2.0-mm-diameter, and 0.6 mm of 2.4-mm-thick urethral wall was preserved. Conclusions Computer simulations suggest that transvaginal approach is more feasible than transurethral approach. Lasers Surg. Med. © 2016 Wiley Periodicals, Inc.

Background There is no consensus regarding the number of intraoperative assessments required to reliably measure trainee performance. This study used generalizability theory (GT) to describe factors contributing to score variance and to estimate the number of assessments needed to achieve high standards of reliability. Methods While performing laparoscopic procedures, trainees were assessed by the attending surgeon using Global Operative Assessment of Laparoscopic Skills (GOALS). Data were collected prospectively (2-month intervals), assessing each trainee multiple times. Reliability coefficient was calculated using trainees, cases, and raters as factors. Results Eighteen trainees were included for a total of 65 assessments. Total variance in scores was accounted for as follows: 66.1% by trainees, 31.6% by the interaction between trainees and cases, and 2.3% by raters. At least 3 cases are required for reliable scores using GOALS. Conclusions Trainees accounted for most of the variance in GOALS scores with a minimum of 3 cases required to improve the reliability of the scores obtained. These data may guide the implementation of performance assessments in surgical training programs.

Objective To determine the cost-effectiveness of enhanced recovery pathways (ERPs) versus conventional care for patients undergoing elective colorectal surgery. Background ERPs for colorectal surgery are clinically effective, but their cost-effectiveness is unknown. Methods A multi-institutional prospective cohort cost-effectiveness analysis was performed. Adult patients undergoing elective colorectal resection at 2 university-affiliated institutions from October 2012 to October 2013 were enrolled. One center used an ERP, whereas the other did not. Postoperative outcomes were recorded up to 60 days. Total costs were reported in 2013 Canadian dollars. Effectiveness was measured using the SF-6D, a health utility measure validated for postoperative recovery. Uncertainty was expressed using bootstrapped estimates (10,000 repetitions). Results A total of 180 patients were included (conventional care: n = 95; ERP: n = 95). There were no differences in patient characteristics except for a higher proportion of laparoscopy in the ERP group. Mean length of stay was shorter in the ERP group (6.5 vs 9.8 days; P = 0.017), but there were no differences in complications or readmissions. Patients in the ERP group returned to work quicker and had less caregiver burden. There was no difference in quality of life between the 2 groups. The cost of the ERP program was $153 per patient. Overall societal costs were lower in the ERP group (mean difference = -2985; 95% confidence interval, -5753 to -373). The ERP had a greater than 99% probability of cost-effectiveness. The results were insensitive to a range of assumptions and subgroups. Conclusions Enhanced recovery is cost-effective compared with conventional perioperative management for elective colorectal resection.

Previous studies have shown that reflectance imaging at wavelengths greater than 1200-nm can be used to image demineralization on tooth occlusal surfaces with high contrast and without the interference of stains. In addition, these near-IR imaging systems can be integrated with laser ablation systems for the selective removal of carious lesions. Higher wavelengths, such as 1950-nm, yield higher lesion contrast due to higher water absorption and lower scattering. In this study, a point-to-point scanning system employing diode and fiber lasers operating at 1450, 1860, 1880, and 1950-nm was used to acquire reflected light images of the tooth surface. Artificial lesions were imaged at these wavelengths to determine the highest lesion contrast. Near-IR images at 1880-nm were used to demarcate lesion areas for subsequent selective carious lesion removal using a new compact air-cooled CO2 laser prototype operating at 9.3-µm. The highest lesion contrast was at 1950-nm and the dual NIR/CO2 laser system selectively removed the simulated lesions with a mean loss of only 12-µm of sound enamel.

The proportion of women in surgery has risen significantly yet there remains gender discrepancies in upper leadership positions in academia. Specialty societies play an important role in academic advancement but the progression of women in surgical societies has not been studied. The purpose of this study was to determine if there are gender differences in advancement within the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) leadership. A retrospective audit of all SAGES committee members (CM) from 1992 to 2018 was performed. The overall membership gender distribution was available from 2010 to 2018. Leadership positions included Committee Chair/Co-chair, Board of Governors, and Executive Committee. Three phenomena were investigated: “pipeline,” by determining the change in women CMs compared to overall membership over time; “sticky floors,” by comparing advancement beyond CM by gender; “glass-ceiling,” by analyzing the promotion trajectory and time to leadership positions between genders. Statistical analysis comparing trends over time was performed using Kendall-tau. There were 1546 surgeons who served on at least one committee during the study period. Women represented 21% of CMs, 18% of chairs/co-chairs, 16% of board members and 14% of executives, with one woman President. The proportion of women CMs has significantly increased over time from 3% in 1992 to 27% in 2018 (p-trend

Zusammenfassung: Nausea und Erbrechen sind häufig. Sie können eine physiologische Antwort auf ein exogenes Toxin sein, aber auch Ausdruck einer organischen, psychischen oder funktionellen Erkrankung. Trotz der Fülle der Differenzialdiagnose gelingt es meist durch sorgfältige Anamnese und wenige Untersuchungen, den Auslöser zu finden. Die Ursachen akuter Beschwerden unterscheiden sich teilweise von denen chronischer. Bei Frauen im gebärfähigen Alter ist eine Schwangerschaft auszuschließen. Eine symptomatische Therapie kann bereits zu Beginn eingeleitet werden. Die Klärung chronischer Ursachen ist schwieriger. Funktionstests wie die Messung der Magenentleerung ergänzen die Diagnostik. Sie sollen nur in spezialisierten Zentren mit entsprechender Erfahrung durchgeführt werden. Ruminieren und Regurgitation sind von Erbrechen abzugrenzen. Findet sich keine Ursache für die Beschwerden, kann von einer funktionellen Erkrankung ausgegangen werden

While processes have been developed to reduce nominal via resistance due to resistive Ta/TaN barrier layers, little effort has been made to show improvements to counteract the shrinking process window for via resistance with technology dimension. An electroless Co via-prefill process can improve nominal resistance, and in this paper, we quantitatively demonstrate improvement in process variability. Through process modeling with virtual fabrication, we also scale this prediction to 7 nm where the variability of the typical Ta/TaN approach is 50% higher with Co via-prefill.

This chapter describes the reduction in shareholder value caused by these inefficiencies—rather than that caused by excessive managerial pay—could well be the biggest cost arising from managerial influence over compensation. Managerial power and influence have played a key role in shaping the amount and structure of executive compensation. The dominant paradigm for economists' study of executive compensation has long been that pay arrangements are the product of arm's-length bargaining. Directors who safeguard shareholder interests are needed not only to address executive compensation problems but also to tackle the myriad corporate governance problems that would continue to arise even if compensation arrangements were optimized. Strengthened director independence is now widely believed to be key to the effectiveness of the board-monitoring model. An improved corporate elections process would be in the interests of both companies and shareholders. A fundamental limitation of independence requirements is that they fail to provide affirmative incentives for directors to enhance shareholder value.

Background: Despite widespread implementation of policies to address mistreatment, the proportion of medical students who experience mistreatment during clinical training is significantly higher than the proportion of students who report mistreatment. Understanding barriers to reporting mistreatment from students’ perspectives is needed before effective interventions can be implemented to improve the clinical learning environment. Objective: We explored medical students’ reasons for not reporting perceived mistreatment or abuse experienced during clinical clerkships at the David Geffen School of Medicine at UCLA (DGSOM). Design: This was a sequential two-phase qualitative study. In the first phase, we analyzed institutional survey responses to an open-ended questionnaire administered to the DGSOM graduating classes of 2013–2015 asking why students who experienced mistreatment did not seek help or report incidents. In the second phase, we conducted focus group interviews with third- and fourth-year medical students to explore their reasons for not reporting mistreatment. In total, 30 of 362 eligible students participated in five focus groups. On the whole, 63% of focus group participants felt they had experienced mistreatment, of which over half chose not to report to any member of the medical school administration. Transcripts were analyzed via inductive thematic analysis. Results: The following major themes emerged: fear of reprisal even in the setting of anonymity; perception that medical culture includes mistreatment; difficulty reporting more subtle forms of mistreatment; incident is not important enough to report; reporting process damages the student–teacher relationship; reporting process is too troublesome; and empathy with the source of mistreatment. Differing perceptions arose as students debated whether or not reporting was beneficial to the clinical learning environment. Conclusions: Multiple complex factors deeply rooted in the culture of medicine, along with negative connotations associated with reporting, prevent students from reporting incidents of mistreatment. Further research is needed to establish interventions that will help identify mistreatment and change the underlying culture.

Complete mesocolic excision (CME) is advocated based on oncologic superiority, but not commonly performed in North America. Many data are case series with few comparative studies. Our aim was to perform a systematic review comparing outcomes between CME and non-CME colectomy. A systematic review was performed according to PRISMA guidelines of MEDLINE, EMBASE, HealthStar, Web of Science, and Cochrane Library. Studies were included if they compared conventional resection (non-CME) to CME for colon cancer. Quality was assessed using methodological index for non-randomized studies (MINORS). The main outcome measures were short-term morbidity and oncologic outcomes. Weighted pooled means and proportions with 95% CI were calculated using a random-effects model when appropriate. Out of 825 unique citations, 23 studies underwent full-text reviews and 14 met inclusion criteria. Mean MINORS score was 13.3 (range 11–15). The mean sample size in CME group was 1166 (range 45–3756) and 945 (range 40–3425) in non-CME. Four papers reported plane of dissection, with CME plane achieved in 85.8% (95% CI 79.8–91.7). Mean OR time in CME group was 167 min (163–171) and 138 min (135–142) in conventional group. Perioperative morbidity was reported in six studies, with pooled overall complications of 22.5% (95% CI 18.4–26.6) for CME and 19.6 (95% CI 13.6–25.5) for non-CME. Anastomotic leak occurred in 6.0% (95% CI 2.2–9.7) of CME resections versus 6.0% (95% CI 4.1–7.9) in non-CME. CME had more lymph nodes, longer distance to high tie, and specimen length in all studies. Nine studies compared long-term oncologic outcomes and only three reported statistically significant higher disease-free or overall survival in favor of CME. Local recurrence was lower after CME in two of four studies. The quality of evidence is limited and does not consistently support the superiority of CME. Better data are needed before CME can be recommended as the standard of care for colon cancer resections.

Previous studies have shown that reflectance imaging at wavelengths greater than 1200-nm can be used to image demineralization on tooth occlusal surfaces with high contrast and without the interference of stains. In addition, these near-IR imaging systems can be integrated with laser ablation systems for the selective removal of carious lesions. Higher wavelengths, such as 1950-nm, yield higher lesion contrast due to higher water absorption and lower scattering. In this study, a point-to-point scanning system employing diode and fiber lasers operating at 1450, 1860, 1880, and 1950-nm was used to acquire reflected light images of the tooth surface. Artificial lesions were imaged at these wavelengths to determine the highest lesion contrast. Near-IR images at 1880-nm were used to demarcate lesion areas for subsequent selective carious lesion removal using a new compact air-cooled CO2 laser prototype operating at 9.3-μm. The highest lesion contrast was at 1950-nm and the dual NIR/CO2 laser system selectively removed the simulated lesions with a mean loss of only 12-μm of sound enamel.

We investigated proposed mechanisms of laser lithotripsy, specifically for the novel, experimental Thulium fiber laser (TFL). Previous lithotripsy studies with the conventional Holmium:YAG laser noted a primary photothermal mechanism (vaporization). Our hypothesis is that an additional mechanical effect (fragmentation) occurs due to vaporization of water in stone material from high absorption of energy, called micro-explosions. The TFL irradiated calcium oxalate monohydrate (COM) and uric acid (UA) stones, as well as artificial stones (Ultracal30 and BegoStone), in air and water environments. TFL energy was varied to determine the relative effect on the ablation mechanism. Scanning electron microscopy (SEM) was used to study qualitative and characteristic changes in surface topography with correlation to presumed ablation mechanisms. Laser irradiation of stones in air produced charring and melting of the stone surface consistent with a photothermal effect and minimal fragmentation, suggesting no mechanical effect from micro-explosions. For COM stones ablated in water, there was prominent fragmentation in addition to recognized photothermal effects, supporting dual mechanisms during TFL lithotripsy. For UA stones, there were minimal photothermal effects, and dominant effects were mechanical. By increasing TFL pulse energy, a greater mechanical effect was demonstrated for both stone types. For artificial stones, there was no significant evidence of mechanical effects. TFL laser lithotripsy relies on two prominent mechanisms for stone ablation, photothermal and mechanical. Water is necessary for the mechanical effect which can be augmented by increasing pulse energy. Artificial stones may not provide a predictive model for mechanical effects during laser lithotripsy.

Previous Thulium fiber laser lithotripsy (TFL) studies were limited to a peak power of 70 W (35 mJ / 500 μs), requiring operation in dusting mode with low pulse energy (35 mJ) and high pulse rate (300 Hz). In this study, a novel, compact, air-cooled, TFL capable of operating at up to 500 W peak power, 50 W average power, and 2000 Hz, was tested. The 1940-nm TFL was used with pulse duration (500 μs), average power (10 W), and fiber (270- μm-core) fixed, while pulse energy and pulse rate were changed. A total of 23 large uric acid (UA) stones and 16 large calcium oxalate monohydrate (COM) stones were each separated into 3 modes (Group 1-“Dusting”- 33mJ/300Hz; Group 2-“Fragmentation”-200mJ/50Hz; Group 3-“Dual mode”-Fragmentation then Dusting). The fiber was held manually in contact with stone on a 2-mm-mesh sieve submerged in a flowing saline bath. UA ablation rates were 2.3±0.8, 2.3±0.2, and 4.4±0.8 mg/s and COM ablation rates were 0.4±0.1, 1.0±0.1, and 0.9±0.4 mg/s, for Groups 1, 2, and 3. Dual mode provided 2x higher UA ablation rates than other modes. COM ablation threshold is 3x higher than UA, so dusting provided lower COM ablation rates than other modes. Future studies will explore higher average laser power than 10 W for rapid TFL ablation of large stones.

A nonsurgical laser procedure is being developed for treatment of female stress urinary incontinence (SUI). Previous studies in porcine vaginal tissues, ex vivo, as well as computer simulations, showed the feasibility of using near-infrared laser energy delivered through a transvaginal contact cooling probe to thermally remodel endopelvic fascia, while preserving the vaginal wall from thermal damage. This study explores optical properties of vaginal tissue in cadavers as an intermediate step towards future pre-clinical and clinical studies. Optical clearing of tissue using glycerol resulted in a 15–17% increase in optical transmission after 11 min at room temperature (and a calculated 32.5% increase at body temperature). Subsurface thermal lesions were created using power of 4.6 – 6.4 W, 5.2-mm spot, and 30 s irradiation time, resulting in partial preservation of vaginal wall to 0.8 – 1.1 mm depth.

The fermionic Green’s functions of QCD exhibit an unexpected property of effective locality, which appears to be exact, involving no approximation. This property is nonperturbative, resulting from a full integration of the elementary gluonic degrees of freedom of QCD. Recalling, correcting, and extending the derivations of effective locality, focus is put on the way nonabelian gauge invariance gets realized in the fermionic nonperturbative regime of QCD.

A central challenge in the regulation of controlled firms is curbing rent extraction by controllers. As independent directors and fiduciary duties are often insufficient, some jurisdictions give minority shareholders veto rights over related-party transactions. To assess these rights' effectiveness, we exploit a 2011 Israeli reform that gave minority shareholders veto rights over related-party transactions, including the pay of controllers and their relatives ("controller executives"). We find that the reform curbed controller-executive pay and led some controller executives to resign or go with little or no pay in circumstances suggesting their pay would be rejected. These findings suggest that minority veto rights can be an effective corporate governance tool.

This amicus brief, filed with the Delaware Supreme Court in Verition Partners v. Aruba Networks, addresses two topics: (i) application of the efficient market hypothesis in appraisal litigation and (ii) empirical scholarship regarding the effect of Delaware appraisal decisions and amendments to 8 Del. C. § 262 on premia in public M&A transactions.

Black & Gilson (1998) argued that an IPO-welcoming stock market stimulates venture deals by enabling VCs to give founders a valuable “call option on control”. We study 18,000 startups to investigate the value of this option. Among firms that IPO, 60% of founders are no longer CEO. With little voting power, only half of the others survive three years as CEO. At initial VC financing, the probability of getting real control of a public firm for three years is 0.4%. Our results shed light on control evolution in startups, and cast doubt on the plausibility of the call-option theory linking stock and VC markets.

Preemptive rights are thought to protect minority shareholders from cheap-stock tunneling by a controlling shareholder. We show that preemptive rights, while making cheap-stock tunneling more difficult, cannot prevent it when asymmetric information about the value of the offered shares makes it impossible for the minority to know whether these shares are cheap or overpriced. Our analysis can help explain why sophisticated investors in unlisted firms and regulators of listed firms do not rely entirely on preemptive rights to address cheap-stock tunneling, supplementing them with other restrictions on equity issues.

This is the publisher’s final pdf. The article is copyrighted by American Geophysical Union and published by John Wiley & Sons, Inc. It can be found at: http://agupubs.onlinelibrary.wiley.com/agu/journal/10.1002/%28ISSN%291944-8007/

Background. The Society of American Gastrointestinal and Endoscopic Surgeons developed the Fundamentals of Endoscopic Surgery (FES) to test the knowledge and skills required to perform flexible endoscopy. The program includes online didactic material to complement the written component, but does not have a practice component for the skills portion. The purpose of this study was to develop and pilot test low-cost models to train for the hands-on component of the FES examination. Methods. Based on the deconstructed skills tested in FES, a low-cost simulator and metrics that model retroflexion, instrumentation and targeting, loop reduction, and mucosal evaluation were developed. The model is reuseable and requires a real endoscope and tower. Validity evidence was obtained by comparing performance between novice endoscopists (NEs) and experienced endoscopists (EEs). Results. Six NEs and 6 EEs participated. In retroflexion, EEs and NEs scored (median [interquartile range]) 72.9 (67.1; 78.6) and 37.9 (25.7; 50.0; P = .004), respectively. In targeting, EEs scored 102.0 (75.0; 110.0) and NEs scored 50.0 (25.0; 50.0; P = .089). In navigation and loop reduction, EEs scored 189.0 (108.0; 267.0) and NEs scored 0.0 (0.0; 0.0; P = .004). In mucosal evaluation, EEs scored 133.3 (103.3; 150.0) and NEs scored 66.7 (50.0; 103.3; P = .015). The median global scores were 116.6 (109.6; 135.8) for EEs and 39.1 (29.1; 40.6; P = .004) for NEs. Conclusion. This pilot study provides preliminary validity evidence to support using these tasks to measure basic flexible endoscopic skills. Subsequent studies will examine the implementation of a proficiency curriculum using this model and its value as a training tool for flexible endoscopy, or to prepare for the FES exam.

A particular choice of renormalization, within the simplifications provided by the non-perturbative property of Effective Locality, leads to a completely finite, non-perturbative approach to renormalized QCD, in which all correlation functions can, in principle, be defined and calculated. In this Model of renormalization, only the Bundle chain-Graphs of the cluster expansion are non-zero. All Bundle graphs connecting to closed quark loops of whatever complexity, and attached to a single quark line, provided no ‘self-energy’ to that quark line, and hence no effective renormalization. However, the exchange of momentum between one quark line and another, involves only the cluster-expansion’s chain graphs, and yields a set of contributions which can be summed and provide a finite color-charge renormalization that can be incorporated into all other QCD processes. An application to High Energy elastic pp scattering is now underway.

The fundamentals of endoscopic surgery (FES) examination measures the knowledge and skills required to perform safe flexible endoscopy. A potential limitation of the FES™ skills test is the size and cost of the simulator on which it was developed (GI Mentor™ II virtual reality endoscopy simulator; Simbionix LTD, Israel). A more compact and lower-cost alternative (GI Mentor™ Express) was developed to address this issue. The purpose of this study was to obtain evidence for the validity of scores obtained on the Express platform, so that it can be used for testing. General surgery residents at various levels of training and practicing endoscopists at five institutions participated. Each completed the five FES tasks on both simulator platforms in random order, with 3–14 days between tests. Scores were calculated using the same standardized computer-generated algorithm and compared using Pearson’s correlation coefficient. There were 58 participants (mean age 32; 76 % male) with a broad range of endoscopic experience. The mean (95 % confidence interval) FES scores were 72 (67:77) on the GI Mentor™ II and 66 (60:71) on the Express. The correlation between scores on the two platforms was 0.86 (0.77:0.91; p

In this paper we illustrate how the predictive Technology Computer Aided Design (TCAD) process device simulation can be used to evaluate process, statistical, and time-dependent variability at the early stage of the development of new technology. This is critically important for the delivery of accurate early Process Design Kits, including process variability, statistical variability, time-dependent variability (degradation) and their interactions and correlations. This is also critical to the TCAD-based Design-Technology Co-Optimisation (DTCO). To accomplish this task, the fast, large area Coventor virtual fabrication platform SEMulator3D was integrated in the GoldStandradSimulations TCAD-based DTCO tool chain. Published data for Intel 22-nm FinFET technology are used to illustrate and validate the results of the TCAD process and device simulation, the compact model extraction, and the statistical circuit simulation.

Background The experimental Thulium fiber laser (TFL) is currently being studied as a potential alternative lithotripter to the clinical gold standard Holmium:YAG laser. Safety studies characterizing undesirable Holmium:YAG laser-induced damage to ureter tissue and stone baskets have been previously reported. Similarly, this study characterizes TFL induced ureter and stone basket damage. Methods A TFL beam with energy of 35 mJ per pulse, pulse duration of 500 µs, and variable pulse rates of 50–500 Hz, was delivered through 100-µm-core optical fibers, to either porcine ureter wall, in vitro, or a standard 1.9-Fr Nitinol stone basket wire. Ureter perforation times were measured and gross, histological, and optical coherence tomography images of the ablation area were acquired. Stone basket damage was graded as a function of pulse rate, number of pulses, and working distance. Results TFL operation at 150, 300, and 500 Hz produced mean ureter perforation times of 7.9, 3.8, and 1.8 seconds, respectively. Collateral damage widths averaged 510, 370, and 310 µm. Nitinol wire damage decreased with working distance and was non-existent at distances greater than 1.0 mm. In contact mode, 500 pulses delivered at pulse rates ≥300 Hz (≤1.5 seconds) were sufficient to cut Nitinol wires. Conclusions The TFL, operated in low pulse energy and high pulse rate mode, may provide a greater safety margin than the standard Holmium:YAG laser for lithotripsy, as evidenced by longer TFL ureter perforation times and shorter non-contact working distances for stone basket damage than previously reported with Holmium:YAG laser. Lasers Surg. Med. 47:403–410, 2015. Lasers Surg. Med. 47:???–???, 2015. © 2015 Wiley Periodicals, Inc.

Objective To compare the incidence of incisional hernia (IH) between midline and transverse specimen extraction site in patients undergoing laparoscopic colectomy. Background Midline specimen extraction incision is most commonly used in laparoscopic colectomy, but has high IH risk. IH may be lower for transverse incision. Methods A single-center superiority trial was conducted. Eligible patients undergoing laparoscopic colectomy were randomly assigned to midline or transverse specimen extraction. Primary outcome was IH incidence at 1 year. Power calculation required 76 patients per group to detect a reduction in IH from 20% to 5%. Secondary outcomes included perioperative outcomes, pain scores, health-related quality of life (SF-36), and cosmesis (Body Image Questionnaire). Results A total of 165 patients were randomly assigned to transverse (n = 79) or midline (n = 86) specimen extraction site, of which 141 completed 1-year follow-up (68 transverse, 73 midline). Patient, tumor, surgical data, and perioperative morbidity were similar. Pain scores were similar on each postoperative day. On intention-to-treat analysis, there was no difference in the incidence of IH at 1 year (transverse 2% vs midline 8%, P = 0.065) or after mean 30.3 month (standard deviation 9.4) follow-up (6% vs 14%, P = 0.121). On per-protocol analysis there were more IH after midline incision with longer follow-up (15% vs 2%, P = 0.013). On intention-to-treat analysis, SF-36 domains body pain and social functioning were improved after transverse incision. Cosmesis was higher after midline incision on per-protocol analysis, but without affecting body image. Conclusions Per-protocol analysis of this trial demonstrates that a transverse specimen extraction site has a lower incidence of IH compared to midline with longer follow-up but has worse cosmesis.

Background: Recurrent carpal tunnel syndrome is often associated with perineural scarring around the median nerve. Surgical options include relatively invasive procedures, such as fat pad grafting, ligament reconstruction, muscle transfer, and nerve wraps. All have limited success because of the possibility of repeated recurrent scarring postoperatively. Methods: We discuss a technique involving injection with external hydroneurolysis of the median nerve under ultrasound guidance for recurrent carpal tunnel. Injection enables a gentler dissection of the surrounding tissues compared with open external neurolysis, with less chance of recurrent scarring. This technique is a unique alternative to repeat operative intervention in recurrent carpal tunnel, as well as a prelude to repeat open decompression and salvage procedures. Results: Ultrasound-guided injection with external hydroneurolysis of the median nerve is a safer, more limited procedure compared with repeat open surgery, usually performed in an office setting. This procedure limits risk, anesthesia, and operating/recovery room expenses, offering relief in 70% to 80% of cases. Furthermore, in the 20% to 30% of patients with inadequate relief, surgery remains a viable option. US provides important information on the anatomy of the median nerve and carpal canal and can rule out covert pathology. Conclusions: We offer an alternative treatment for recurrent carpal tunnel syndrome, a difficult problem for which many surgeons recommend nonoperative treatment. US provides objective data concerning residual nerve compression and allows for dynamic assessment. Theoretically, this also offers a viable solution for surgeons and their patients with recurrent carpal tunnel syndrome before being pressed to consider repeat open surgery.

While evidence supports early compared to delayed cholecystectomy as optimal management of acute calculous cholecystitis (ACC), significant variability in practice remains. The purpose of this study was to identify variables associated with early cholecystectomy, to target opportunities to improve adherence to best practices. Adult patients admitted to surgical units with ACC at two hospitals in a university hospital network between June 2010 and January 2015 were reviewed. Patients with concurrent pancreatitis, cholangitis or severe ACC (with organ system failure) were excluded. Early cholecystectomy was defined as surgery performed during same admission and within 7 days of presentation. Non-operative management was defined as admission for ACC treated conservatively, with or without eventual delayed cholecystectomy. The primary outcome was early cholecystectomy versus initial non-operative management; secondary outcomes included time to cholecystectomy, complications, and total hospital length of stay (LOS). A total of 374 patients were included. Two hundred and forty six patients (66%) underwent early cholecystectomy, 60 (16%) were treated non-operatively and had delayed cholecystectomy, and 68 (18%) were only treated non-operatively. Median time to OR from initial presentation was 38 h [22–63] for early cholecystectomy patients and 69 days [29–116] for the non-operative patients who had delayed cholecystectomy. When comparing both groups, early cholecystectomy patients were younger and were treated more often at site 1. There were no differences in complications during hospitalization, but early cholecystectomy patients had a lower median total LOS (3 [2–5] vs. 5 [4–9], p