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Magnetic resonance cholangiography (MRC) is a non-invasive imaging modality that has become widely available. In the short time since its introduction, MRC has been shown to possess excellent accuracy for the diagnosis of various biliary pathologies, including choledocholithiasis. Investigations of the clinical applications of MRC are ongoing. This review summarizes the diagnostic capabilities of MRC and discusses its application in the management of patients with gallstone diseases.

Hypothesis: We hypothesized that physician assistants (PAs) will decrease surgery resident work hours and improve resident work outlook., Design: Surgical resident survey., Setting: A county hospital in a university-based surgical residency program., Participants: Surgery residents who switched (or "rotated") to the county hospital were polled monthly for 6 months after using PAs as team members on the surgical services., Main Outcome Measures: Resident work hours and work outlook., Results: Surgery resident hours were significantly decreased by the fourth, fifth, and sixth months after PAs joined the surgical services. Despite what these data on resident hours suggest, 6 (60%) of 10 residents believed that the PAs had no influence on the amount of time the residents spend in the hospital. Six (60%) of 10 residents thought the PAs decreased stress levels and 6 (60%) of 10 residents thought the PAs helped to improve morale., Conclusions: Physician assistants can have a positive influence on graduate surgical education programs. Physician assistants can help decrease surgery resident work hours and improve resident work outlook.

Background: Common duct calculi retained after gallbladder surgery continue to present a clinical challenge especially in the era of minimally invasive surgery. This review examines the strategy of dissolution therapy used throughout the history of biliary tract surgery and its use to the modern surgeon., Data Sources: Original journal articles and reviews were identified using standard surgical textbooks and MEDLINE. Keywords for searching included choledocholithiasis, dissolution, mono-octanoin, common duct stones, MTBE, cholic acid, and gallstones., Conclusions: Dissolution therapy used initially as an alternative to open surgery is now used more effectively as an adjunct to laparoscopic or endoscopic biliary tract surgery. The current review demonstrates a majority of patients with retained choledocholithiasis respond to dissolution and can be safely managed without choledochotomy.

Thyroglossal duct cysts (TDCs), the most common congenital cervical abnormality, originates from the medial anlage of the thyroid gland and presents as a painless asymptomatic midline suprahyoid mass. It does not represent a diagnostic challenge. The tract may persist as a fibrous cord or leave nests of cells anywhere along its embryonic path, and it gives rise to the development of TDC. The Sistrunk operation described in 1920 consists of en bloc cystectomy and central hyoidectomy, with tract excision up to the foramen cecum. This procedure remains an effective treatment for TDC. Malignant degeneration of TDC is rare (0.7%).

Hypothesis: Resident operative experience has increased or decreased with respect to 12 specific operations., Design: A retrospective analysis of resident operative experience reported to the Accreditation Committee for Graduate Medical Education for academic years 1990-1997., Subjects: Residents completing an Accreditation Committee for Graduate Medical Education surgical program., Main Outcome Measures: The total number of residents, average number of operations performed per resident, and the most common operations performed., Results: The number of house staff completing surgical residency training programs has remained constant, while operative volume has increased from 1991 to 1997. Comparison of the frequencies of 12 selected operative procedures performed in academic years 1990-1991 and 1996-1997 found increases in the following procedures: carotid endarterectomy (137%), pancreaticoduodenectomy (66.7%), laparoscopic cholecystectomy (64.8%), parathyroidectomy (51.2%), thyroidectomy (19.2%), colectomy (14.1% to 44.4% depending on subtype), and elective infrarenal aortic aneurysm repair (10.7%). Conversely, frequencies decreased for open cholecystectomy (63.4%), open parietal cell vagotomy (40%), modified radical mastectomy (15.2%), gastroesophageal antireflux procedure (10.4%), and subtotal gastric resection (8.93%). Resident experience was essentially unchanged for emergent infrarenal aortic aneurysm repair and laparoscopic proximal gastric vagotomy., Conclusions: The number and variety of operative interventions in surgical therapeutics is changing. Continued analysis of the operative experience during surgical training will indicate the need for changing requirements for surgical resident experience. The causes of these shifts are not specifically addressed by this study. Perhaps technological advances in the diagnosis and management of surgical patients or the increase in subspecialty training programs have affected the experience of general surgery trainees.

Ethics codes and guidelines date back to the origins of medicine in virtually all civilizations. Developed by the medical practitioners of each era and culture, oaths, prayers, and codes bound new physicians to the profession through agreement with the principles of conduct toward patients, colleagues, and society. Although less famous than the Hippocratic oath, the medical fraternities of ancient India, seventh-century China, and early Hebrew society each had medical oaths or codes that medical apprentices swore to on professional initiation. The Hippocratic oath, which graduating medical students swear to at more than 60% of US medical schools, is perhaps the most enduring medical oath of Western civilization. Other oaths commonly sworn to by new physicians include the Declaration of Geneva (a secular, updated form of the Hippocratic oath formulated by the World Medical Association, Ferney-Voltaire, France) and the Prayer of Moses Maimondes, developed by the 18th-century Jewish physician Marcus Herz.

Hypothesis: To determine if a cause-effect relationship exists between crack cocaine use and duodenal ulcer perforation (DUP)., Patients and Methods: A retrospective study was conducted of all patients undergoing emergency surgical management for peptic ulcer disease over a 6-year period at a large inner-city municipal teaching hospital. The hospital records of 78 consecutive patients presenting with complications of peptic ulcer disease between April 1990 and April 1996 were reviewed. Group A (n = 24) consisted of patients with confirmation of crack cocaine usage within 8 hours of clinical presentation; group B (n = 54) consisted of patients with no antecedent history of crack cocaine use. Demographic data, timing of drug use, clinical presentation, laboratory and radiographic findings, toxicology screening, operative findings, and postoperative course were compared between the two groups., Results: Both groups revealed a similar gender distribution, tobacco use, prior peptic ulcer symptoms, and laboratory findings. Group A patients were younger (t test, P = 0.01) and more likely to present with perforation, whereas patients in group B presented with a combination of symptoms (chi square, P = 0.03). Duodenal ulcer perforation was present in 75% of patients in group A compared with 46% of patients in group B (chi square, P = 0.04). Group B patients had a significantly longer hospital stay compared with those in group A (t test, P = 0.01). Both crack cocaine and alcohol are independent predictors of duodenal ulcer perforation., Conclusions: Patients with recent use of crack cocaine and/or alcohol are more likely to present with duodenal perforations. Although a temporal association between crack cocaine use and duodenal ulcer perforation was demonstrated, this study does not confirm a cause-effect relationship. A prospective cohort study is needed to clarify the pathogenesis of this potential cause-effect relationship.

The aim of this study was to determine if the experience of general surgery residents is adequate and effective. The Resident Statistic Summaries (Report C) of the Residence Review Committee (Surgery) for eight academic years from 1986 to 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed. For adrenalectomy, the average per resident was 0.98. The maximum range was from 7 to 15. The standard deviations ranged from 1.12 to 2.00. For pancreatic endocrine operations the average per resident was 0.15 with maximums of 3 to 10. For other endocrine procedures (nonthyroid and nonparathyroid) the average per resident was 0.14, with the maximums ranging from 7 to 19. The most common number of any of these procedures performed by U.S. graduates was 0. The number of adrenal, endocrine pancreas, and other less common endocrine procedures available for graduates of U.S. residency training programs is limited. As a consequence, most U.S. resident graduates have little or no experience with any of these procedures. Our findings suggest a strong need for fellowship training for any surgeon hoping to develop expertise in the management of these unusual and infrequent endocrine surgical diseases.

Objectives: To evaluate the causes of necrotizing soft-tissue infections (NSTls) and to determine the outcomes of patients with NSTls., Design: A restrospective survey of the causes and factors associated with the outcomes., Setting: An urban community hospital serving an indigent population., Patients: A consecutive series of patients with NTSls who were treated between December 11, 1990, and December 28, 1995., Interventions: Patients were treated with operative debridement, intravenous antibiotics, and supportive measures., Main Outcome Measures: Patient outcomes, causes, the extent of infection, the health status of the patients, causative organisms, and treatment delays., Results: Forty-five patients with NSTls were identified. Twenty-eight cases (62%) have occurred since January 13, 1994. Parenteral drug abuse, the causative event in 25 cases (56%), accounted for 21 (75%) of the 28 cases identified since January 13, 1994. Skin flora were the primary isolates in 18 (40%) of the cases; 78% of these flora were polymicrobial. Clostridial species were isolated in 8 (18%) of the cases. The overall mortality was 27%. Survivors had less extensive infections and were more stable hemodynamically than nonsurvivors. Patients with necrosis and cellulitis greater than 250 cm2 were less likely to survive than those with less extensive infections. Logistic regression analysis identified the extents of infection, the initial blood pressure, and the initial temperature as independent predictors of outcome in this patient series., Conclusions: This is 1 of the largest reported series of patients with NSTls in which parenteral drug abuse is a prevalent causative factor. The proportion of NSTls attributable to the injection of illicit substances has increased notably in the past 2 years and has reached epidemic proportions. Survivors of NSTls had less extensive infections and were more often hemodynamically stable than nonsurvivors. Clostridial species were common in patients with NSTls related to parenteral drug abuse, underscoring the need for awareness of the potential for wound botulism in these patients.

Background: The objective of this study was to assess the diagnostic and therapeutic effectiveness of videothoracoscopy in thoracic trauma patients., Methods: The design was a retrospective review. The setting was a major trauma center at an urban county hospital. Forty-one hemodynamically stable patients sustaining thoracic trauma were reviewed (34 penetrating and 7 blunt injuries). In the acute setting (< 24 h), videothoracoscopy was used for continued bleeding(6) and suspected diaphragmatic injury(17). Thoracoscopy was used in delayed settings (> 24 h) for treatment of thoracic trauma complications(18) including clotted hemothorax(14), persistent air leak(1), widened mediastinum(1), and suspected diaphragmatic injury(2)., Results: The average Injury Severity Score (ISS) of these patients was 18.9 +/- 10.0. Three of 6 patients (50%) with continued bleeding were successfully treated thoracoscopically. Nine of 10 (90%) diaphragmatic injuries were confirmed by thoracoscopy, and 7 of these 9 patients (77%) were repaired thoracoscopically. Thirteen of 14 patients (93%) with clotted hemothoraces and one with a persistent air leak were treated successfully using thoracoscopy. An aortic injury was ruled out in one patient., Conclusions: Videothoracoscopy is a safe, accurate, minimally invasive, and potentially cost-effective method for the diagnosis and therapeutic management of thoracic trauma patients.

Background: We wanted to determine whether the experience of general surgery residents is adequate and effective., Methods: The Resident Statistic Summaries (Report C) of the Residency Review Committee (Surgery) for 8 academic years from 1986 through 1994 were analyzed. The main outcome measurements were total number of residents and programs, average number of operations performed, maximum number of operations performed, standard deviation, and the most common number of operations performed., Results: For thyroidectomy the average per resident ranged from 10.3 to 12.6. The maximum ranged from 52 to 102. The standard deviations ranged from 6.96 to 8. The most common number of thyroidectomies performed ranged from 7 to 10 per graduating resident. For parathyroidectomy the average ranged from 4.1 to 5.1, the standard deviations were 3.44 to 4, the maximum ranged from 25 to 60, and the most common number performed was 2., Conclusions: U.S. graduates have highly variable experience in thyroid and parathyroid surgery. Most residents have inadequate experience in parathyroid surgery and marginal experience in thyroid surgery.

Purpose: To assess the therapeutic potential of emergent laparoscopy in the trauma setting, a retrospective review was performed in a busy urban trauma center., Patients and Methods: Between December 1991 and October 1993, 133 hemodynamically stable patients with suspected abdominal injury were evaluated laparoscopically. All laparoscopic procedures were performed in the operating room under general anesthesia. Mechanism of injury was stab wound (58), gunshot wound (57), and blunt trauma (18). No significant injuries were found in 72 patients (54%), and these patients received no further treatment. On the basis of laparoscopic findings, 52 patients underwent formal exploratory laparotomy. Surgical exploration confirmed the presence of significant injuries in 44 of the 52 patients (85%). Therapeutic laparoscopy was performed in 6 patients (5%) for diaphragm repair (4), gastrotomy repair (1), and splenorrhaphy (1). Additionally, 10 patients underwent laparoscopy-guided blood salvage for autotransfusion during laparoscopic evaluation of blunt trauma. Three small-bowel enterotomies were repaired during minilaparotomy., Results: No significant injuries were missed as a result of our use of laparoscopy in trauma assessment. Complications--trocar enterotomy, trocar laceration of the inferior epigastric artery, and transient hypotension--occurred in 3 patients secondary to the use of laparoscopy., Conclusions: Trauma laparoscopy is a safe method for the evaluation of selected patients with abdominal trauma and can reduce the number of negative and nontherapeutic trauma laparotomies performed. Limited therapeutic intervention is possible in a small number of patients.