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Objectives: To describe financial toxicity (FT) in patients who have undergone gastrointestinal (GI) surgery and its correlation with patients' emotional (EWB) and social well-being (SWB)., Background: FT describes the financial burden associated with treatment and its impact on patient outcomes. Few prior studies have examined FT in gastrointestinal surgery and its impact on patient quality of life., Methods: Patients who underwent gastrointestinal surgery at our institution were assessed for FT with a validated instrument between Jan 2022 and Jan 2023. EWB and SWB were assessed with a validated instrument. Risk factors for FT were determined using a multivariable model. The correlation between FT and patient EWB and SWB was assessed using Pearson correlation., Results: 188 patients were surveyed, the majority had pancreatic resections (n = 90, 47.9%), 59 (31.4%) patients experienced FT. On multivariable analysis, categories associated with increased likelihood of exhibiting financial toxicity included single marital status and not receiving chemotherapy and/or radiation therapy, with odds ratio (95% C.I) of [3.02 (1.07, 8.51), P=.037] and [3.86 (1.3, 11.44), P=.015) respectively. Higher EWB and SWB scores directly correlated with higher FT scores., Conclusion: Patients undergoing complex gastrointestinal surgery often experience financial toxicity that affects patient reported outcomes. Financial toxicity is associated with identifiable pre-operative factors that can be utilized to screen patients for interventions that may mitigate some of the harmful effects of FT., Competing Interests: The authors report no conflicts of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: American Board of Surgery (ABS) In-Training Examination (ITE), or ABSITE, preparation requires an effective study approach. In 2014, the ABS announced the alignment of ABSITE to the SCORE® Curriculum. We hypothesized that implementing a Plan-Do-Study-Act (PDSA) approach would help surgery residents improve their performance on the ABSITE., Method: Over 20 years, in a single institution, residents' ABSITE performance was evaluated over 3 timeframes: Time A (2004-2013), no specific curriculum; Time B (2014-2019), an annual comprehensive ABSITE-simulated SCORE®-based multiple-choice exam (MCQ) was administered; and Time C (2020-2023), like Time B with the addition of the PDSA approach for those with less than 60% correct on the ABSITE-simulated SCORE®-based exam. At the beginning of the academic year, in July, all residents are encouraged to (1) initiate a study plan for the upcoming ABSITE using SCORE® guided by the published ABSITE outlines content topics (Plan), (2) take an ABSITE-simulated SCORE®-based exam in October (Do), (3) assess the results/scores (Study), and (4) identify appropriate next steps (Act). Correlational analysis was performed to evaluate the association between ABSITE scores and ABSITE-simulated SCORE®-based exam scores in Time B and Time C. The primary outcome was the change in the proportions of ABSITE scores <30 th percentile., Results: A total of 294 ABSITE scores of 94 residents (34 females and 60 males) were analyzed. We found stronger correlation between the correct percentage on ABSITE and ABSITE-simulated SCORE®-based exam scores in Time C (r = 0.73, p < 0.0001) compared to Time B (0.62, p < 0.0001). The percentage of residents with ABSITE scores lower than 30 th percentile dropped significantly from 14.0% to 3.7% (p = 0.016)., Conclusion: Implementing the Plan-Do-Study-Act (PDSA) approach using the SCORE® curriculum significantly enhances residents' performance on the ABSITE exam. Surgery residents are encouraged to use this approach and to utilize the SCORE-contents outlined by the ABS in their study plan., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

This study examines the safety and efficacy of using peak anti-Xa levels to achieve prophylactic enoxaparin (Lovenox, Sanofi-Aventis) levels in patients who underwent hepatic surgery. Prospectively enrolled patients undergoing major and minor hepatic procedures received postoperative enoxaparin dosing. The enoxaparin dose was adjusted to attain a peak anti-Xa level ≥ 0.20 U/ml. This group was compared to a historical cohort of patients who underwent similar procedures and received standard postoperative VTE chemoprophylaxis dosing. Inpatient postoperative VTE rates were higher in the control group when compared to the experimental group (0 patients [0.00%] vs 4 patients [8.16%]; P = .035). There was no statistically significant difference in number of postoperative blood transfusions, discharge hemoglobin, or in-hospital bleeding events. Adjusting enoxaparin dosing to achieve prophylactic peak anti-Xa levels of ≥0.20 IU/ml was associated with a reduced incidence of symptomatic inpatient postoperative VTE in patients who underwent hepatic surgery without increasing postoperative bleeding events., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Importance: This study aimed to identify both modifiable and nonmodifiable factors that affect intraoperative-specific surgical education and performance, with an overall goal of increasing cognizance of such factors to improve surgical training., Objective: To determine whether surgery residents prepare adequately for participation in surgical cases and to examine specific variables that affect resident preparation., Design: This study is a retrospective survey-based study that included data from 1945 postoperative case evaluations completed by 59 different general surgery residents over a period of 8 years (2014-2022)., Setting: A Midwestern medical school's general surgery residency program., Participants: Fifty-nine general surgery residents at Western Michigan University's medical school; 50 attending surgeons and faculty with whom residents regularly operate. The sample was comprised of residents and attendings who voluntarily filled out postoperative performance surveys after elective cases., Results: This retrospective survey-based study included postoperative evaluation data from 1945 procedures performed by 59 different residents and 50 attendings. Participants included 36 male residents, 23 female residents, 39 male attendings, and 11 female attendings. All included data were for elective cases. Self-reported preoperative communication was worst at the PGY1 level with positive correlation of improvement yearly (r = 0.30, p < 0.001). Positive correlation was seen between overall preparedness and case complexity (r = 0.25, p < 0.001). Positive correlation was seen between case complexity and resident perception of intraoperative teaching quality (r = 0.53, p < 0.001). Preoperative communication initiated by residents was significantly worse when the attending surgeon was female, regardless of resident gender (p < 0.001); this effect was particularly profound with male residents. Male residents overall rated themselves as more prepared compared to their female counterparts (11.13 ± 1.96 vs. 10.84 ± 2.03, p = 0.003)., Conclusions and Relevance: There is a need to identify and address quantifiable gaps in communication between residents and faculty to optimize surgical education; one of the first steps is characterizing nonmodifiable factors that correlate with differences in pre-operative communication and case preparation., (Published by Elsevier Inc.)

Background: Surgical site infection (SSI) is a common, morbid post-operative complication. We hypothesized the presence of racial differences in SSI rates, comparing black/African American (BAA) to white non-Hispanic (WNH) patients. Patients and Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), BAA and WNH surgery patients across 10 surgical specialties were identified: general surgery (GS), vascular surgery (VS), cardiac surgery (CS), thoracic surgery (TS), orthopedics (OS), neurosurgery (NS), urology (US), otolaryngology (ENT), plastic surgery (PS), and gynecology (GYN). The primary outcome was SSI rate (superficial, deep incisional, or organ/space). The secondary outcome was rate of non-surgical infection. Pearson χ 2 and Fisher exact tests were used to test group differences of categorical variables. Continuous variables were tested with the Student t-test, or Mann-Whitney U test, with statistical significance set at a value of p < 0.05. Multivariable logistic regression models were conducted to analyze the association between race/ethnicity and the infection outcomes. Results: A total of 740,144 patients were included: 99,425 (13.4%) BAA and 640,749 (86.6%) WNH, distributed as follows; 32,2976 GS, 17,6175 OS, 44,383 VS, 2,227 CS, 9,645 TS, 42,298 NS, 42,726 US, 18,518 ENT, 20,709 PS, and 60,517 GYN cases. Surgical site infection rates were higher among WNH in GS (4.4% vs. 4.1%; p = 0.003) and TS (3.1% vs. 1.7%; p = 0.015); lower in VS (3.2% vs. 4.4%; p < 0.001), OS (1.2% vs.1.6%; p < 0.001), and GYN (2.4% vs. 3%; p < 0.001); and similar between WNH and BAA in ENT (1.8% vs 1.8%; p = 0.76), and US (1.9% vs. 1.9%; p = 0.90). Non-surgical infection was higher in BAA in NS (3.2% vs. 2.5%; p = 0.003), and higher in WNH in GYN (2.6% vs. 2%; p < 0.001), OS (1.7% vs. 1.1%; p < 0.001), US (4.4% vs. 3.6%; p = 0.014), and VS (3.4% vs. 2.6%; p < 0.001). Conclusions: Variation exists in SSI rates between WNH and BAA patients among surgical subspecialties. Further research is required to understand these differences and address racial disparities in outcomes.

Background: As announced by the Federation of State Medical Boards (FSMB) and National Board of Medical Examiners (NBME), the United States Medical Licensing Examination (USMLE) Step 1 score reporting has transitioned to pass/fail outcomes instead of the traditional numeric score after January 26, 2022. USMLE Step 1 scores have been used widely as a crucial tool in screening and selecting applicants for residency programs. This study aims to determine the role of USMLE Step 2 in the selection of applicants for general surgery residency., Methods: A retrospective study was conducted over six recruiting cycles from 2016 to 2021. The data from 334 interviewed applicants from one general surgery residency program were assessed. Data analyzed included USMLE Step 1 and Step 2 scores, applicant gender, Alpha Omega Alpha (AOA) status, letters of recommendation (LOR), and research/publications (RS)., Results: Of the 334 interviewed applicants, 209 (62.6%) were male. The mean [SD] USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores were 239.6 [±10.4] and 249.2 [±11.4], respectively. The mean (SD) LOR and RS scores were 4.24 [±0.4] and 3.9 [±0.7], respectively. A positive correlation was observed between USMLE Step 1 and USMLE Step 2 C K (Clinical Knowledge) scores ( r  = 0.60, p  < .001), LOR scores ( r  = 0.24, p  = .008), and AOA status ( r  = 0.19, p  = .038). There was a negligible correlation between USMLE scores and applicant gender., Conclusion: Transitioning USMLE Step 1 to pass/fail will make the initial screening and selection process of applications challenging for residency programs. In the short term, USMLE Step 2 scores, LOR, and AOA status are important as screening assessments. Valid measures to ensure appropriate, equitable, and fair assessments are needed., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Background: Femoral hernias are associated with significant morbidity and mortality due to risk of strangulation. Frailty has shown to be strongly associated with adverse outcomes. A modified five-factor frailty index (mFI-5) is a simple validated predictor of postoperative complications and mortality within the ACS-NSQIP ® database. This study aims to evaluate the impact of frailty and age on 30-day outcomes after femoral hernia repair., Methods: Patients who underwent femoral hernia repair were queried using the ACS-NSQIP database (2017) and divided into two groups based on frailty score (FS): Frail (FS = 1-5) and Non-frail (FS = 0). We evaluated the association between postoperative outcomes and frailty, age, sex, presentation, ASA class, timing of surgery, and surgical approaches. Univariate analysis followed by a multivariable logistic regression model was performed to evaluate postoperative morbidity., Results: Of a total of 1,295 patients, 540 (42.7%) were in the Frail group. No differences in sex and race proportions were observed between groups. The Frail group had a higher rate of serious morbidity (4.4% vs 1.9%, P < .001), overall morbidity (7.8% vs 3.4%, P < .010), readmission rate (5.4% vs 2.3%, P = .003), and median (IQR) hospital length of stay (1 [0, 4] vs 0 [0, 1] days, P < .001). In multivariable analysis, male sex, presentation with complication, emergency surgery, and FS were associated with increased odds of overall morbidity. All deaths were in the Frail group., Conclusion(s): Frailty, male sex, presentation with obstruction/strangulation, and emergency surgery are independent predictors of increased 30-day morbidity. Thirty-day mortality was noted in the Frail group.

Despite the high global prevalence of endometriosis, little is known about the experiences of women living with the disease in low- and middle-income contexts, including in Kenya and other countries across sub-Saharan Africa. This study captures the perspectives and recommendations of Kenyan women living with endometriosis through written narratives about the impact of the disease on their daily lives and their journeys through diagnosis and treatment. Thirty-seven women between the ages of 22 and 48 were recruited from an endometriosis support group in Nairobi and Kiambu, Kenya (February-March of 2022) in partnership with the Endo Sisters East Africa Foundation. Narrative data (written anonymous stories submitted through Qualtrics) were analyzed using a deductive thematic analysis methodology. Their stories revealed three themes related to their shared experiences with endometriosis: (1) stigma and disruption to quality of life, (2) barriers to acceptable healthcare, and (3) reliance on self-efficacy and social support to cope with the disease. These findings demonstrate a clear need for improved social awareness of endometriosis in Kenya and the establishment of clear, effective, and supportive pathways, with trained, geographically and financially accessible health care providers, for endometriosis diagnosis and treatment.

Background: Recommended prophylactic doses of enoxaparin (Lovenox) are associated with subprophylactic anti-Factor Xa (anti-Xa) levels. This study examines the safety and efficacy of anti-Xa-guided dosing of enoxaparin in pancreatic surgery., Methods: Prospectively enrolled patients undergoing pancreatic surgery received enoxaparin dosing adjusted based on peak anti-Xa levels and were compared to a historical cohort of patients., Results: Baseline characteristics were similar between the intervention and control groups. In the intervention group, 73.9% initially had subprophylactic peak anti-Xa levels. There were no differences in the venous thromboembolism (VTE) rates between the intervention and control groups (0% vs. 7.69%; P = .084), major bleeding events (4.35% vs. 2.56%; P = .627), RBC transfusion (15.2% vs. 25.6%; P = .257), or Hgb on discharge (9.82 vs. 9.44 g/dL; P = .244). Subtherapeutic anti-Xa levels were correlated with a higher BMI ( P = .033), longer OR time ( P = .011), and length of stay ( P = .018)., Conclusions: Enoxaparin 40 mg once daily is associated with subprophylactic peak anti-Xa levels. Dose adjustment based on anti-Xa levels trended toward a lower rate of in-hospital VTE without an increase in bleeding or transfusion requirement.

Introduction: Appropriate faculty supervision and conditional independence of residents during training are required for autonomous and independent postgraduate practice. However, there is a growing concern that competence for transition to independent practice is not universally met. We hypothesize that surgery residents play a significant and active role in achieving their own independent status., Methods: Over seven academic years (July 2014 through June 2021), 46 surgeons supervised and intraoperatively assessed the performance of 51 residents using validated Objective Structured Assessment of Technical Skill (OSATS) and Zwisch Operative Autonomy (ROA) assessments. Resident readiness to perform procedures independently (RRI) was graded as yes, no, or not applicable. Data were analyzed using descriptive statistics with categorical variables reported as frequencies and percentages., Results: A total of 1657 elective procedures were performed by residents supervised by faculty. Association between RRI and postgraduate year (PGY), OSATS scores, ROA, resident and faculty gender, and case complexity was analyzed. Results indicated positive correlation between RRI and summative OSATS score (r = 0.510, P < 0.001), PGY (r = 0.535, P < 0.001) and ROA (r = 0.473, P < 0.001). Percentage of overall RRI increased from 7% at PGY1 to 87.4% at PGY5. Meaningful autonomy ratings increased from 23.6% at PGY1 to 92.5% at PGY5. Variations in ratings was observed when considering case category and complexity., Conclusions: RRI increases with years of training with variation when considering the specialty/The Accreditation Council for Graduate Medical Education procedure category and the complexity of cases. Specialty fellowships are a viable option to address the gap in The Accreditation Council for Graduate Medical Education categories when residency alone cannot reach appropriate independence. Residents' technical skills play a crucial role in evaluating RRI and granting operative autonomy., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: The objective of this study is to determine the factors influencing pancreatic surgery patients' perceptions of the shared decision-making process (SDM)., Background: Decision-making in pancreatic surgery is complicated by the risk of morbidity and mortality and risk of early recurrence of disease. Improvement in SDM has the potential to improve the receipt of goal- and value-concordant care., Methods: This cross-sectional survey included patients who underwent pancreatic surgery. The following components were studied in relation to SDM: modified satisfaction with decision scale (SWD), modified decisional regret scale (DRS), quality of physician and patient interaction, and the impact of quality of life (FACT-Hep). Correlations were computed using Pearson's correlation score and a regression model., Results: The survey completion rate was 72.2% (of 40/55) and the majority (72.5%) of patients underwent pancreaticoduodenectomy. There were significant positive relationships between the SDM measure and (DRS, SWD; r = 0.70, P < 0.001) and responses to questions regarding how well the patient's actual recovery matched their expectations before treatment ( r = 0.62, P < 0.001). The quality of the physician-patient relationship correlated with how well recovery matched expectations ( r = 0.53, P = 0.002). SDM measure scores were significant predictors of the decision evaluation measure ( R 2 (adj) = 0.48, P < 0.001), FACT-Hep ( R 2 (adj) = 0.15, P < 0.001), and recovery expectations measure ( R 2 (adj) = 0.37, P < 0.001)., Conclusions: Improved SDM in pancreatic surgery is associated with more realistic recovery expectations, decreased decisional regret, and improved quality of life., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction Biliary cancers are rare cancers with poor prognoses. In this study, we aimed to evaluate trends in early detection and surgical treatment and approaches in extra-hepatic biliary tract cancers (EBCs) over 13 years in the US. Methods The most recent data on patients diagnosed with EBC between 2004 and 2016 were extracted from the National Cancer Database (NCDB). The patients' demographics (sex, age, race), primary tumor sites, tumor grades and stages, staging modalities, diagnostic confirmation, surgical treatment modalities and approaches, and 90-day mortality were analyzed to determine trends. Results Biopsy was the most common staging modality in 63.9% of total 60,291 patients. The bile duct was the primary tumor site (55.0%). Histologic examination was the most common confirmatory diagnostic modality (77.5%). The most common stage was stage II (23%). The most common surgical treatment modality was radical surgery (13.88%). The open surgical approach was used in 27.1% of patients, followed by a laparoscopic approach (4.3%). Conclusion EBC showed no significant change in the trends of the stage at diagnosis, treatment modality, and extent of surgical procedures despite advances in surgical diagnostic and therapeutic modalities; however, the total number of cases slightly increased between 2004 and 2016., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Tuma et al.)

Background: The extent to which age impacts surgical outcomes remains poorly characterized. This study aims to evaluate the impact of age on 30-day outcomes in patients after distal pancreatectomy., Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database (2017), distal pancreatectomy patients were identified and age-stratified, groups A (≤75 years) and B (>75 years). Outcomes included 30-day mortality, morbidity, readmissions, operative time (min), and hospital length of stay (LOS, days)., Results: Of 3042 total patients identified, 1686 (55.4%) were women. A total of 2649 patients (87.1%) were in group A. Overall, both groups had similar baseline characteristics with the exception of the following: diabetes mellitus (24.8% vs. 30.0%, P = .03), smoking (19.3% vs. 4.8%, P < .001), congestive heart failure (.5% vs. 1.8%, P = .010), hypertension (HTN) (47.9% vs. 72.5%, P < .001), bleeding disorders (3.1% vs. 5.3%, P = .036), the American Society of Anesthesiologists (ASA) (III-V) scores (67.6% vs. 85.5%, P < .001), and body mass index (29.2 [±6.7] vs. 27.4 [±5.6], P = .001).Deep surgical site infection was higher in group A (12.1% vs. 6.6%, P = .001), while acute renal failure (ARF) and postoperative myocardial infarction (MI) were higher in group B. 30-day readmissions were higher in group A (17.4% vs. 12.2%, P = .011) despite no statistically significant difference in LOS (7.10 [±6.36] vs. 7.30 [±4.93] days, P = .553) or overall morbidity (29.4% vs. 28.8%, P = .859)., Conclusion(s): Those undergoing distal pancreatectomy experienced similar overall morbidity and mortality outcomes regardless of age. However, those older than 75 years had more cardiovascular risk factors, which may have contributed to their higher rates of postoperative ARF and MI.

Introduction: The American Board of Surgery In-Training Examination (ABSITE) is a crucial, objective assessment of surgical knowledge during training. In 2014, the American Board of Surgery (ABS) announced the alignment of the ABSITE to the SCORE® (Surgical Council on Resident Education) Curriculum Outline for General Surgery Residency. We hypothesized that implementing a pre-ABSITE SCORE-based exam would help identify underperforming residents and provide early guidance to improve performance on the ABSITE., Methods: In October 2014, our university-based surgical residency program began administering a yearly comprehensive pre-ABSITE SCORE-based exam consisting of 225 to 250 multiple-choice questions selected from the SCORE question bank to all our general surgery residents, preliminary and categorical. The 4-hour exam addresses both clinical management (80%) and applied sciences (20%). Residents receive reports with their scores (percentage correct). Residents performing at less than 60% meet with the Program Director for discussion and formulation of a study plan. Correlational analysis was performed between resident ABSITE scores, pre-ABSITE SCORE-based exam scores, gender, resident status (preliminary vs. categorical), postgraduate year (PGY), and the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores., Results: A total of 244 exam scores (122 pre-ABSITE SCORE-based exams and 122 matched ABSITE) were completed by 51 residents at different PGY levels (32 PGY1, 32 PGY2, 20 PGY3, 19 PGY4, and 18 PGY5). Fifty-seven percent were males, 62% were categorical residents, and 38% were preliminary residents. October pre-ABSITE SCORE-based exam scores were compared to the subsequent January ABSITE scores. Categorical residents completed 101 (83%) of the January exams, while preliminary residents completed 21 (17%) of these paired exams. We found strong correlations between the correct percentage on ABSITE and pre-ABSITE SCORE-based scores (r = 0.637, p < 0.001), between the correct percentage on ABSITE and PGY (r = 0.688, p < 0.001), and between ABSITE and resident status (r = 0.462, p < 0.001). Additionally, there was a weak to negligible correlation between the correct percentage on ABSITE and resident gender (r = 0.274, p = 0.001), USMLE-2 (r = 0.12, p = 0.16), and USMLE-1 (r = 0.04, p = 0.653). Multiple regression analysis, with all predictors, was performed to predict the percentage score on the ABSITE and produced R 2 0.58, with an adjusted R 2 of 0.57, with a large size effect, p < 0.001. After controlling for the other variables, three factors reached statistical significance (p < 0.05): pre-ABSITE SCORE-based exam scores, PGY, and resident gender., Conclusion: We found a strong correlation between performance on the pre-ABSITE SCORE-based exam and performance on the ABSITE exam. Surgery residents are encouraged to start studying earlier and to utilize SCORE contents as outlined by the ABS in their study plan., (Copyright © 2021 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Introduction: Traditional in-person Mock Oral Examinations (IP-MOEs) are utilized by surgery residency programs to prepare trainees for the American Board of Surgery Certifying Exam (ABS-CE). However, the COVID-19 Pandemic has led to a profound disruption of on-campus and in-person educational activities, with subsequent instantaneous revolutionization of educational systems all over the world, including a massive switch to virtual platforms. Many in-person didactics and examinations were canceled or rescheduled, including the ABS-CE. The study aims to evaluate Virtual MOEs' (V-MOEs) feasibility as a potential alternative to in-person MOEs in residency programs., Methods: Twenty-five participants-16 general surgery residents (7 females, 9 males) and 9 faculty - in the inaugural Department of Surgery Virtual Mock Oral Examination completed an anonymous, voluntary online survey via Microsoft Forms. Faculty was given 24 questions, and residents 28, with 9 questions common between both residents and faculty. Participants were asked about the accessibility to virtual examination rooms, V-MOE effectiveness, resident's preparation for the exam, resident's stress, diversity, and number of clinical scenarios, and possible future implementation of, and barriers to, V-MOEs., Results: All participants have participated in IP-MOEs in the past. All faculties were very satisfied or satisfied with IP-MOE, compared to 93.8% of residents. All participants were very satisfied or satisfied with the orientation and instructions before V-MOE. Only 66.6% of faculty, compared to all residents, was satisfied with time allocation for sessions. While 88.9% of faculty felt the V-MOE was less stressful on residents, only 68.8% of residents felt so. Additionally, 87.5% of residents said they prepared for the V-MOE similarly to the IP-MOE. As a future platform, only 22.2% of faculty compared to 43.8% of residents preferred V-MOE over the IP-MOE. Both faculty (88.9%), and residents (81.3%) preferred immediate feedback at the end of sessions. All faculty recommend collaboration with other programs to enhance the resident's preparation. Time constraints, lack of experience with the format, and availability were the top 3 barriers., Conclusion: V-MOE is feasible, accessible, and a potential alternative for IP-MOEs at a program level for ABS-CE preparation. Given the time constraints and costs associated with IP-MOEs, it is an opportunity to collaborate with other residency programs., (Copyright © 2020 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Resident operative autonomy (ROA) is critical and a shared responsibility of both faculty and residents during training. We hypothesize that there is a perception of gender bias in residents' performance as evaluated by faculty and residents., Method: Over a period of five academic years, between July 2014 and June 2019, ROA was evaluated using the Zwisch score. Reciprocal evaluations were completed by faculty and residents., Results: 39 surgeons (30 males, 9 females) and 42 residents (25 males, 15 females) completed 2360 evaluations (1180 by faculty, and a matched number by residents). PGY level was significantly associated with granting a higher level of autonomy. Gender of residents didn't affect the level of granted autonomy as evaluated by faculty. However, on self-evaluations, female residents rated their degree of autonomy lower than that of their male counterparts., Conclusion: Gender did not influence the perception of autonomy granted as evaluated by faculty. However, on self-evaluations, female residents reported a lower degree of autonomy received., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Studies of gender disparity in surgical training have yielded conflicting results. We hypothesize that there is no influence of gender on resident self-evaluation Milestone (SEM) scores and those assigned by the Clinical Competency Committee (CCC)., Methods: 42 residents (25 male & 17 female) and faculty completed 300 Accreditation Council for Graduate Medical Education (ACGME) Milestone evaluations over a 4-year period. Two-way ANOVA, intraclass correlations coefficients, and general linear mixed models were used for analysis., Results: CCC Milestone scores from 150 evaluations, 51 (34%) for female residents and 99 (66%) for male residents, were compared to corresponding SEM scores. There is a high interrater reliability (self vs. CCC). There was a significant increase in scores with advancing PGY levels (p < 0.001). No effect of gender on Milestones scores (p > 0.05) was noted., Conclusions: We found no significant differences in Milestones scores between male and female residents as determined by the CCC. Both scores improved significantly as residents progressed in training., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Despite the well-established relationship between volume and outcomes, patients continue to have procedures performed at low-volume hospitals. The factors patients use to make the complex decision of where to have hepatopancreaticobiliary (HPB) surgery remain poorly characterized. A novel survey instrument was administered to all patients who had undergone HPB surgery at two university-affiliated community hospitals. 76 patients participated in the study (89% response rate). The majority of patients were unaware of the volume-outcome relationship (58.8%). No demographic factors differed between patients who were or were not aware except for patient research. Physician factors were the most important selection category (64.4%). Only 28.9% of patients were willing to travel more than two hours to have an operation performed at a hospital with a high volume/improved quality. Despite many voices calling for regionalization, patient decision-making factors should be considered before any realistic implementation., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Chou et al.)

Background: Studies among populations at high risk of venous thromboembolism (VTE) have demonstrated that recommended doses for enoxaparin thromboprophylaxis are associated with high incidence of subprophylactic anti-factor Xa (anti-Xa) levels. This study examines the efficacy and safety of dose-adjusted enoxaparin guided by anti-Xa levels., Study Design: Patients undergoing abdominal cancer operation had dose adjustments based on peak anti-Xa levels to attain a target of >0.20 IU/mL were prospectively enrolled and compared with a historic cohort of patients receiving recommended thromboprophylaxis. Incidence of in-hospital VTE and major bleeding after changes in enoxaparin dosing were monitored., Results: The study population comprised 197 patients-64 patients in the prospective intervention group and 133 patients in the control group. Baseline characteristic were similar between the intervention and control groups, with the exception of the Caprini score (8.09 vs 7.26; p = 0.013). In the intervention group, 50 of 64 patients (78.1%) initially had subprophylactic peak anti-Xa levels. The VTE rates were lower in the intervention group than the control group (0% vs 8.27%; p = 0.018). There were no differences in major bleeding events (3.12% vs 1.50%; p = 0.597), rates of postoperative packed RBC transfusion (17.2% vs 23.3%; p = 0.426), or mean Hgb on discharge (9.58 vs 9.37g/dL; p = 0.414). Therapeutic anti-Xa levels correlated positively with age (65.7 vs 58.2 years; p = 0.022) and correlated negatively with operating room time (203 vs 281 minutes; p = 0.032) and BMI (25.3 vs 29.2 kg/m 2 ; p = 0.037)., Conclusions: Thromboprophylactic enoxaparin 40 mg daily is often associated with subprophylactic peak anti-Xa levels. Dose adjustment based on anti-Xa levels increased the daily enoxaparin dose, resulting in a lower rate of in-hospital VTE without increased risk of bleeding., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to evaluate the role of surgical transgastric necrosectomy (TGN) for walled-off pancreatic necrosis (WON) in selected patients., Background: WON is a common consequence of severe pancreatitis and typically occurs 3 to 5 weeks after the onset of acute pancreatitis. When symptomatic, it can require intervention., Methods: A retrospective review of patients with WON undergoing surgical management at 3 high-volume pancreatic institutions was performed. Surgical indications, intervention timing, technical methodology, and patient outcomes were evaluated. Patients undergoing intervention <30 days were excluded. Differences across centers were evaluated using a P value of <0.05 as significant., Results: One hundred seventy-eight total patients were analyzed (mean WON diameter = 14 cm, 64% male, mean age = 51 years) across 3 centers. The majority required inpatient admission with a median preoperative length of hospital stay of 29 days (25% required preoperative critical care support). Most (96%) patients underwent a TGN. The median duration of time between the onset of pancreatitis symptoms and operative intervention was 60 days. Thirty-nine percent of the necrosum was infected. Postoperative morbidity and mortality were 38% and 2%, respectively. The median postoperative length of hospital length of stay was 8 days, with the majority of patients discharged home. The median length of follow-up was 21 months, with 91% of patients having complete clinical resolution of symptoms at a median of 6 weeks. Readmission to hospital and/or a repeat intervention was also not infrequent (20%)., Conclusion: Surgical TGN is an excellent 1-stage surgical option for symptomatic WON in a highly selected group of patients. Precise surgical technique and long-term outpatient follow-up are mandatory for optimal patient outcomes.

Introduction: Autonomy, both operative and nonoperative, is one of the most critical aspects of successful surgical training. Both surgeon and resident share the responsibility of achieving this goal. We hypothesize that operative autonomy is distinct and depends, for the most part, on the resident's manual dexterity, knowledge of, and preparation for the procedure., Methods: Over a period of 4 academic years, between July 2014 and June 2018, a total of 958 Global Rating Scale of Operative Performance evaluations were completed by 32 general and subspecialty faculty surgeons for 35 residents. Elective procedures were evaluated, including 165 (17.2%) by postgraduate year (PGY)1 residents, 253 (26.4%) by PGY2, 199 (20.8%) by PGY3, 147 (15.3%) by PGY4, and 194 (20.3%) by PGY5. The procedures evaluated were: 261 (27.2%) hernia repairs; 178 (18.6%) cholecystectomies; 102 (10.6%) colorectal and anal procedures; 73 (7.6%) vascular procedures; 56 (5.8%) thyroid and parathyroidectomies; 39 (4.1%) foregut (esophagus and stomach) procedures; 38 (4%) skin, soft tissue, and breast; 92 (10%) hepatopancreatic; 20 (2.1%) pediatric procedures; and 99 (10.3%) other procedures including amputations, cardiothoracic, and solid organs procedures. Each resident was scored from 1 to 5 (1 lowest, 5 highest) in each of the following categories of Global Rating Scale of Operative Performance: respect for tissue (RT), time and motion (T&M), instrument handling (IH), knowledge of the instrument (KI), flow of operation (FO) and resident's preparation for the procedure (RP). Resident operative autonomy (ROA) was assessed using the Zwisch scale, a 4-point scale describing faculty supervision behaviors associated with different degrees of resident autonomy (1: Show and Tell, 2: Active Help, 3: Passive Help, and 4: Supervision Only)., Results: Correlation and ordinal regression analyses were conducted to examine the relationship between ROA and manual dexterity (RT, T&M, IH, and FO), and cognitive functioning (knowledge of instruments and resident preparation). Results indicated a positive correlation between ROA and RT (r = 0.528, p < 0.001), T&M (r = 0.630, p < 0.001), IH (r = 0.597, p < 0.001), KI (r = 0.490, p < 0.001), FO (r = 0.637, p < 0.001), and RP (r = 0.525, p < 0.001). Additionally, there was a weak inverse correlation between ROA and the number of years the surgeon had been in practice (r = -0.127, p = 0.001). The significant predictors of resident autonomy found by the ordinal logistic regression include time and motion (p < 0.001), flow of operation (p < 0.001), and resident's preparation for the procedure (p < 0.001)., Conclusions: Resident operative autonomy is a product of shared responsibility between the faculty and resident. However, residents' inherent and/or acquired skills and preparation for the operative procedures play a critical role. Residents should be advised to use available resources such as simulation to augment their skills preoperatively and to enhance their autonomy in the operating room., (Copyright © 2019 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: In hepato-pancreato-biliary (HPB) surgery higher volumes are associated with improved outcomes; however, there are limitations to regionalization. Here we report our experience establishing multidisciplinary HPB program at a university-affiliated community hospital., Methods: This is a retrospective review of patients who underwent HPB surgery between 2015 and 2017. Chief residents' HPB case logs were collected., Results: 61 pancreatic resections and 62 hepatic resections were performed. The morbidity, 30-day mortality and median length of stay following pancreatic resections were 27%, 1.5%, and 8 days, respectively. The morbidity, 90-day mortality, and median length of stay following hepatic resections were 24%, 3%, and 7 days, respectively. The median pancreatic and liver case volumes for graduating chief residents increased from 7 to 8 to 16 and 16, respectively (p < 0.05), after the establishment of a HPB program. Participation in multidisciplinary care (p = 0.08) and clinical trial enrollment increased., Conclusion: Our study demonstrates short-term outcomes comparable to high volume centers. Development of a HPB program had a positive impact on resident operative experience, increased multidisciplinary care and increased clinical trial enrollment., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Intrahepatic cholangiocarcinoma (IHC) is a malignancy with an increasing incidence. Surgery is the only treatment modality associated with long term survival. The objective of this study is to utilize a nationwide representative database to quantify the trends in incidence, and surgery for IHC in the United States from 2004-2014, as well as identify any disparities in the receipt of surgery., Methods: All patients admitted with a diagnosis of IHC between 2005 and 2014 were identified from the Nationwide Inpatient Sample (NIS) database. Trends in the number of IHC admissions and surgery procedures as well as outcomes were examined, and a multivariate analysis was used to determine the effects of demographic and clinical co-variables on resection rates., Results: An estimated total of 104,045 IHC related admissions occurred between 2005 and 2014. The hospitalization rate for IHC increased by nearly 2-fold in 2014 [38.9 per 100,000 (95% CI, 35.7-42.2)] from 18.1 per 100,000 (95% CI, 15.8-20.3) in 2005. Liver resections increased 248% (P<0.01) with an increasing majority being performed at teaching hospitals and 56% being minor resections. There was an increase in estimated hospital charges from $87,124 to $148,613 (P<0.001) and decrease in LOS from 12 days to 10 days (P<0.01). Inpatient mortality for IHC decreased significantly from 11% to 8.4% (P=0.004), from year 2005 to 2014 respectively. Age >80 years (OR =0.45; 95% CI, 0.33-0.60), Black race (OR =0.50; 95% CI, 0.39-063), Hispanic race (OR =0.59; 95% CI, 0.45-0.79), Medicaid insurance (OR =0.58; 95% CI, 0.42-0.79) and Elixhauser comorbidity score >3 (OR =0.58; 95% CI, 0.47-0.73) were associated with decreased rates of resection., Conclusions: Overall hospitalization and volume of surgery for IHC has increased dramatically over the past decade. There has been an increase in cost, decrease in LOS and inpatient mortality during the period. Socioeconomic and racial disparities were observed in the receipt of surgery for IHC. Additional work is needed to understand the complex interplay between socioeconomic status and race in in the treatment of IHC., Competing Interests: Conflicts of Interest: Presented at the SSAT’s 59th Annual Meeting at Digestive Disease Week, June 2-5, 2018, in Washington, DC.

Introduction: Ranking candidates for residency positions is challenging. We hypothesize that applicant academic achievements and performance during the interview are equally important in the ranking process., Methods: This is a retrospective study. Of 53 candidates interviewed during 2016-2017 cycle, 44 (83%) were ranked for 3 PGY1 positions. Each candidate was interviewed and scored in each of the following: USMLE Step 1 score, USMLE Step 2 score, research (RS), letters of recommendation (LOR), personal statement (PS), the way the candidate represented him/herself (RP), interest in the area (IN), answers to standardized questions (SQ), and degree of connection between the candidate and the interviewer (CN)., Results: Correlation and multiple regression analyses indicated an inverse relationship between ranking the candidates and USMLE2 (r = -0.14, p = -0.364), LOR (r = -0.513, p < 0.001), PS (r = -0.414, p = 0.006), RP (r = -0.485, p = 0.001), CN (r = -0.605, p < 0.001), IN (r = -0.349, p = 0.022), and SQ (r = -0.480, p = 0.001), USMLE1 (r = -0.036, p = 0.838) and RS (r = -0.008, p = 0.96). After controlling for the other variables, only CN reached statistical significance (p = 0.033)., Conclusion: Candidate non-cognitive measures during the interview weigh higher than academic performance in the ranking process., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) offers a potential cure for peritoneal carcinomatosis (PC), whereas aborted cytoreduction is associated with a poor outcome. We evaluate factors associated with aborted CRS procedures., Methods: An IRB approved retrospective review was performed from 12/2011 to 2/2016. Clinicopathologic variables and outcomes are described., Results: Seventy-four patients underwent attempted CRS/HIPEC which was completed in 51 (69%) and aborted in 23 (31%). There was no difference in age, race, gender or prior treatment between groups. Patients who underwent aborted procedures had a higher peritoneal cancer index (PCI, 26.1±9.9 vs . 16.2±10.5, P=0.001). Overall survival (OS) was significantly improved for patients who underwent completed CRS/HIPEC (41.0±10.4 vs. 6.0±2.3 months, P<0.0001). Patients with an appendiceal and colorectal primary who underwent CRS/HIPEC had a significantly better outcome (median not reached vs. 6±5.4 months, P<0.0001, and 28.0±7.5 vs. 8.0±4.0 months, P<0.0001, respectively). Colorectal pathology (P=0.014) and PCI score (<0.0001) were independent predictors of aborted CRS procedures., Conclusions: One-third of patients with PC had significant disease which prevented successful completion of CRS/HIPEC. PCI and colorectal primary tumor pathology were associated with a greater likelihood of aborted CRS procedures., Competing Interests: Conflicts of Interest: This work was presented in part at the 11th Annual Regional Therapies Meeting, February 13–15, 2016, Phoenix, AZ, and the American College of Surgeons Clinical Congress, October 17–20, 2016, Washington, DC, USA.

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) has improved outcomes for selected patients with peritoneal carcinomatosis and often requires ostomy creation. We examined the impact of ostomy creation in a newly established peritoneal malignancy program. A retrospective review was performed of CRS-HIPEC procedures from 2011 to 2016. Those who did and did not receive an ostomy were compared. Fifty-eight patients underwent CRS-HIPEC and an ostomy was created in 25.9 per cent. Median peritoneal cancer index (14 vs 16, P = 0.63) and multivisceral resection rates (87.9 vs 100.0%, P = 0.17) were similar between groups. Multivariable analysis revealed that bowel resection (OR 210.65, P = 0.02) was significantly associated with ostomy creation. Advanced age was noted to be inversely associated with stoma formation (OR 0.04, P = 0.04). Progression-free survival was significantly lower in the ostomy group (18 vs 23 months, P = 0.03). Those with an ostomy experienced prolonged length of stay (13.3 ± 7.4 vs 9.5 ± 3.7, P = 0.01). At follow-up, 6/10 temporary ostomies had undergone reversal and three patients experienced morbidity after reversal. Ostomy creation may occur during CRS-HIPEC and carries potential for morbidity. Ostomy creation may contribute to postoperative length of stay. Patients should be counseled preoperatively on the potential impact of ostomy placement during CRS-HIPEC.

Although significant progress has been made in improving breast cancer survival, disparities among racial, ethnic, and underserved groups still exist. The goal of this investigation is to quantify racial disparities in the context of breast cancer care, examining the outcomes of recurrence and mortality in the city of Memphis. Patients with a biopsy-proven diagnosis of breast cancer from January 1, 2002, through December 31, 2012, were obtained from the tumor registry. Black patients were more likely to have advanced (II, III, or IV) clinical stage of breast cancer at diagnosis versus white patients. Black breast cancer patients had a two times higher odds of recurrence (95% confidence interval: 1.4, 3.0) after adjusting for race and clinical stage. Black breast cancer patients were 1.5 times more likely to die (95% confidence interval: 1.2, 1.8), after adjusting for race; age at diagnosis; clinical stage; ER, PR, HER2 status; and recurrence. Black women with stages 0, I, II, and III breast cancer all had a statistically significant longer median time from diagnosis to surgery than white women. Black patients were more likely to have advanced clinical stages of breast cancer at diagnosis versus white patients on a citywide level in Memphis. Black breast cancer patients have higher odds of recurrence and mortality when compared with white breast cancer patients, after adjusting for appropriate demographic and clinical attributes. More work is needed to develop, evaluate, and disseminate interventions to decrease inequities in timeliness of care for breast cancer patients.

Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) has improved outcomes for patients with peritoneal carcinomatosis (PC). We present our experience from a newly developed peritoneal surface malignancy program., Methods: An IRB approved retrospective review was performed for the first 50 patients treated with CRS/HIPEC with clinicopathologic data described., Results: Patients treated with CRS/HIPEC were Caucasian (64%), female (66%) with a median age of 53 years (range, 11-73 years). Primary pathology included: appendix (40%, n=20), ovary (20%, n=10), colon (14%, n=7), desmoplastic small round cell tumor (14%, n=7) or other (12%, n=6). The median peritoneal cancer index (PCI) score was 15.5 (range, 1-39) and 92% underwent complete cytoreduction (CCR 0/1). Median hospital length of stay was 9.0 days (range, 6-35 days). Eight patients (16%) suffered major morbidity with 2 (4%) 30-day mortalities., Conclusions: Short-term outcomes observed after CRS/HIPEC in a newly developed center for PC are consistent with published higher volume center experiences., Competing Interests: Conflicts of Interest: This work was presented in part at the 69th Southwestern Surgical Congress annual meeting, April 2-5, 2017, Maui, HI.

Background: Thromboelastography has called into question the coagulopathy seen following partial hepatectomy. However the coagulation profile in cirrhotic livers has not been studied. Our objective was to determine the coagulation profile following partial hepatectomy in normal and cirrhotic livers., Methods: Patients undergoing liver resection were prospectively enrolled in the study. The prothrombin time and international normalized ratio, as well as the thromboelastogram, were obtained preoperatively, post-operatively, and on post-operative days 1, 3, and 5., Results: 22 noncirrhotic and 11 cirrhotic patients undergoing liver resection were enrolled. Postoperatively the thromboelastogram demonstrated a hypercoagulable profile in 64%, 33%, 39% and 36% of patients on post-operative days 0, 1, 3 and 5 respectively. There was no difference between patients with cirrhosis and those without underlying liver disease., Conclusion: Patients appear to have a similar coagulation profile after liver resection regardless of underlying cirrhosis with many having a hypercoagulable profile., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Breast-conservation surgery with radiotherapy is a treatment highly recommended by the guidelines from the National Comprehensive Cancer Network. However, several variables influence the final receipt of radiotherapy and it might not be administered to breast cancer patients. Our objective is to propose a systematic framework to identify the clinical and non-clinical variables that influence the receipt of unexpected radiotherapy treatment by means of Bayesian networks and a proposed heuristic approach., Methods: We used cancer registry data of Detroit, San Francisco-Oakland, and Atlanta from years 2007-2012 downloaded from the Surveillance, Epidemiology, and End Results Program. The samples had patients diagnosed with in situ and early invasive cancer with 14 clinical and non-clinical variables. Bayesian networks were fitted to the data of each region and systematically analyzed through the proposed Zoom-in heuristic. A comparative analysis with logistic regressions is also presented., Results: For Detroit, patients under stage 0, grade undetermined, histology lobular carcinoma in situ, and age between 26-50 were found more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients with age between 51-75, and grade II were found to be more likely to receive breast-conservation surgery with radiotherapy. For San Francisco-Oakland, patients under stage 0, grade undetermined, and age >75 are more likely to receive BCS. For stages I, IIA, and IIB patients with age >75 are more likely to receive breast-conservation surgery without radiotherapy. For Atlanta, patients under stage 0, grade undetermined, year 2011, and primary site C509 are more likely to receive breast-conservation surgery without radiotherapy. For stages I, IIA, and IIB patients in year 2011, and grade III are more likely to receive breast-conservation surgery without radiotherapy., Conclusion: For in situ breast cancer and early invasive breast cancer, the results are in accordance with the guidelines and very well demonstrates the usefulness of the Zoom-in heuristic in systematically characterizing a group receiving a treatment. We found a subset of the population from Detroit with ductal carcinoma in situ for which breast-conservation surgery without radiotherapy was received, but potential reasons for this treatment are still unknown.

Improved oncological outcomes after cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) in highly selected patients have been well documented. The extensive nature of the procedure adversely affects quality of life (QoL). The aim of this study is to longitudinally evaluate QoL following CRS/HIPEC. This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC. Clinicopathological data, oncologic outcomes, and QoL were analyzed preoperatively and postoperatively at 2 weeks, and 1, 3, 6, and 12 months. The Functional Assessment of Cancer Therapy-Colorectal instrument was used to determine changes in QoL after CRS/HIPEC and the impact of early recurrence (<12 months) on QoL. Thirty-six patients underwent CRS/HIPEC over 36 months. The median peritoneal cancer index score was 18 and the completeness of cytoreduction-0/1 rate was 97.2 per cent. Postoperative major morbidity was 16.7 per cent with one perioperative death. Disease-free survival was 12.6 months in patients with high-grade tumors versus 31.0 months in those with low-grade tumors (P = 0.03). QoL decreased postoperatively and improved to baseline in six months. Patients with early recurrence had a decrease in global QoL compared with preoperative QoL at 6 (P < 0.03) and 12 months (P < 0.05). This correlation was not found in patients who had not recurred. Patients who undergo CRS/HIPEC have a decrease in QoL that plateaus in 3 to 6 months. Early recurrence adversely impacts QoL at 6 and 12 months. This study emphasizes the importance of patient selection for CRS/HIPEC. The expected QoL trajectory in patients at risk for early recurrence must be carefully weighed against the potential oncological benefit of CRS/HIPEC.

Background: Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare and unique variant of hepatocellular carcinoma (HCC) whose presentation remains inadequately described. We present a resectable case of FL-HCC which involved tumor thrombus of the common bile duct., Presentation: A 27 year-old male presenting with jaundice, abdominal pain, vomiting, hepatic dysfunction and hyperbilirubinemia was found to have a large liver mass and lymphadenopathy on preoperative imaging. A right hepatectomy with perihepatic lymph node dissection and cholecystectomy was performed. Intraoperative cholangiogram demonstrated common bile duct (CBD) obstruction. CBD exploration revealed biliary tumor thrombus relieved with biliary thrombectomy., Discussion: FL-HCC can initially present with invading obstructing biliary tumor thrombus of the CBD causing jaundice., Conclusion: Preoperative surgical approach should consider CBD exploration on an individual basis for underlying obstructive biliary tumor thrombus., (Published by Elsevier Ltd.)

Background: Outcome measures after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) for peritoneal carcinomatosis in established centers are well defined. However, results from newly emerging US centers have not been reported., Methods: This is a retrospective review of a prospectively maintained database of patients with peritoneal malignancies undergoing CRS/HIPEC., Results: Fifty-six patients underwent exploratory laparotomy with 36 receiving CRS/HIPEC over 36 months. The median peritoneal cancer index score was 18, and the cytoreduction 0/1 rate was 92%. Postoperative major morbidity was 16.7% with one perioperative death. The median length of hospital stay and intensive care unit days were 9 and 3 days, respectively. Disease-free survival in high-grade vs low-grade tumors was 12.6 and 31.0 months (P, .03), respectively. Average direct cost for patients undergoing CRS/HIPEC was $25,917., Conclusions: Our emerging center's short-term results are comparable with established programs with a trend toward more selective intraoperative judgment on who undergoes CRS/HIPEC., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Primary squamous cell carcinoma (SCC) of the gallbladder is a rare malignancy of the gallbladder, accounting for less than 5% of gallbladder pathology. Initial presentation is often similar to adenocarcinoma of the gallbladder. SCC tends to be more locally aggressive, however, and possesses a worse prognosis than adenocarcinoma. We report a case of locally advanced SCC of the gallbladder.

Neuroendocrine tumors (NETs) comprise a broad family of tumors that may or may not be associated with symptoms attributable to hormonal hypersecretion. The NCCN Clinical Practice Guidelines in Oncology for Neuroendocrine Tumors discuss the diagnosis and management of both sporadic and hereditary NETs. This selection from the guidelines focuses on sporadic NETs of the pancreas, gastrointestinal tract, lung, and thymus., (Copyright © 2015 by the National Comprehensive Cancer Network.)

Background: World Health Organization's essential drugs list can control the highly prevalent HIV-related pain and symptoms. Availability of essential medicines directly influences clinicians' ability to effectively manage distressing manifestations of HIV., Aim: To determine the availability of pain and symptom controlling drugs in East Africa within President's Emergency Plan for AIDS Relief-funded HIV health care facilities., Design: Directly observed quantitative health facilities' pharmacy stock review. We measured availability, expiration and stock-outs of specified drugs required for routine HIV management, including the World Health Organization pain ladder., Setting: A stratified random sample in 120 President's Emergency Plan for AIDS Relief-funded HIV care facilities (referral and district hospitals, health posts/centres and home-based care providers) in Kenya and Uganda., Results: Non-opioid analgesics (73%) and co-trimoxazole (64%) were the most commonly available drugs and morphine (7%) the least. Drug availability was higher in hospitals and lower in health centres, health posts and home-based care facilities. Facilities generally did not use minimum stock levels, and stock-outs were frequently reported. The most common drugs had each been out of stock in the past 6 months in 47% of facilities stocking them. When a minimum stock level was defined, probability of a stock-out in the previous 6 months was 32.6%, compared to 45.5% when there was no defined minimum stock level (χ (2) = 5.07, p = 0.024)., Conclusion: The data demonstrate poor essential drug availability, particularly analgesia, limited by facility type. The lack of strong opioids, isoniazid and paediatric formulations is concerning. Inadequate drug availability prevents implementation of simple clinical pain and symptom control protocols, causing unnecessary distress. Research is needed to identify supply chain mechanisms that lead to these problems.

Mesenteric cysts are rare intra-abdominal cysts that are generally regarded as benign, and the incidence of malignancy is often cited to be 3%. The typical recommendation for treatment is complete excision to minimize recurrence. Excision can be performed laparoscopically, but this can lead to intra-abdominal dissemination of the cyst contents. There has been one case report describing the development of pseudomyxoma peritonei following rupture of a mesenteric cyst. We describe the treatment and outcome of a patient who underwent cytoreductive surgery with hyperthermic intraperitoneal chemotherapy for the treatment of an incompletely resected mucinous cystadenocarcinoma originating from the colonic mesentery.

Background: End-of-life care needs are great in Africa due to the burden of disease. This study aimed to explore public preferences and priorities for end-of-life care in Nairobi, Kenya., Methods: Population-based street survey of Kenyans aged ≥18; researchers approached every 10th person, alternating men and women. Structured interviews investigated quality vs. quantity of life, care priorities, preferences for information, decision-making, place of death (most and least favourite) and focus of care in a hypothetical scenario of serious illness with <1 year to live. Descriptive analysis examined variations., Results: 201 individuals were interviewed (100 women) representing 17 tribes (n = 90 44.8%, Kikuyu). 56.7% (n = 114) said they would always like to be told if they had limited time left. The majority (n = 121, 61.4%) preferred quality of life over quantity i.e. extending life (n = 47, 23.9%). Keeping a positive attitude and ensuring relatives/friends were not worried were prioritised above having pain/discomfort relieved. The three most concerning problems were pain (45.8%), family burden (34.8%) and personal psychological distress (29.8%). Home was both the most (51.1% n = 98) and least (23.7% n = 44) preferred place of death., Conclusion: This first population-based survey on preferences and priorities for end-of-life care in Africa revealed that psycho-social domains were of greatest importance to the public, but also identified variations that require further exploration. If citizens' preferences and priorities are to be met, the development of end-of-life care services to deliver preferences in Kenya should ensure an holistic model of palliative care responsive to individual preferences across care settings including at home.