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Background: Obesity has increased progressively in the United States and is a known risk factor for several diseases such as type 2 diabetes, coronary artery disease, stroke and hypertension. Amid the current pandemic, concerns have been raised about obesity as a risk factor for COVID-19 positive patients. The primary goal of this study was to explore the association between obesity and hospital mortality in COVID-19 patients. Our secondary objective was to explore the relationship between obesity and race on hospital mortality in COVID-19 patients., Methods: This was a cross-sectional, retrospective analysis using data from 186 hospitals from across the United States and the United Kingdom during the first quarter of 2020. Extraction provided data from 25,894 patients who were tested for COVID-19, of whom 2,977 were positive. Patients were stratified into standard WHO categories for BMI and by race., Results: Bivariate analysis revealed significant relationships between mortality and sex (p<0.001) When BMI was analyzed as a continuous variable, multivariate analysis revealed a significant influence of BMI on mortality (odds ratio=1.291, p<0.05)., Conclusion: COVID-19 mortality was significantly related to BMI, age and select co-morbidities, but race/ethnicity was not a predictor of mortality when controlling for other variables., Competing Interests: Conflicts of Interest The authors declare they have no conflicts of interest., (© 2021 HCA Physician Services, Inc. d/b/a Emerald Medical Education.)

Background: Surgical techniques for abdominal wall hernia repair have advanced, yet it is unclear if all patient populations experience these innovations equally. We hypothesized that in patients undergoing abdominal wall herniorrhaphy, there would be socioeconomic variation between robotic, laparoscopic, and open approaches., Methods: We performed a retrospective review of patients undergoing abdominal wall herniorrhaphy at a tertiary care center from 2013 through 2019. Patients were stratified by approach: laparoscopic (LH), open (OH), or robotic (RH). Insurance type was categorized as private, Medicare, or Medicaid/uninsured. Using zip code data, we obtained a Distressed Communities Index (DCI), which is comprised of 7 unique socioeconomic variables. We employed random forest (RF) modeling to predict surgical approach and determined each factor's variable importance (VI) for our model., Results: There were 559 patients; 39.7% (n = 222) LH, 33.3% (n = 186) OH, and 27% (n = 151) RH. The DCI (p < 0.01) and rates of poverty (p = 0.01), adults without diplomas (p < 0.01), and unemployment (p < 0.01) were highest in the OH group while job growth (p = 0.02) and median income ratio (p < .01) were highest in the RH group. The LH group had a greater proportion of privately insured patients than Medicaid/ uninsured patients (43.4% vs 15.9%, p < 0.01). The most important variables identified by our RF model were job growth (for RH), insurance type (for LH), and no high school diploma (for OH)., Conclusion: Insurance type, job growth, and educational attainment may influence operative approach and can contribute to the existing disparities in hernia surgery. Surgeons should address these inequalities and commit to parity in the delivery of surgical care.

Objective: To study the effects of fatigue on general surgery residents' performance on the da Vinci Skills Simulator (dVSS)., Methods: 15 General Surgery residents from various postgraduate training years (PGY2, PGY3, PGY4, and PGY5) performed 5 simulation tasks on the dVSS as recommended by the Robotic Training Network (RTN). The General Surgery residents had no prior experience with the dVSS. Participants were assigned to either the Pre-call group or Post-call group based on call schedule. As a measure of subjective fatigue, residents were given the Epworth Sleepiness Scale (ESS) prior to their dVSS testing. The dVSS MScore™ software recorded various metrics (Objective Structured Assessment of Technical Skills, OSATS) that were used to evaluate the performance of each resident to compare the robotic simulation proficiency between the Pre-call and Post-call groups., Results: Six general surgery residents were stratified into the Pre-call group and nine into the Post-call group. These residents were also stratified into Fatigued (10) or Nonfatigued (5) groups, as determined by their reported ESS scores. A statistically significant difference was found between the Pre-call and Post-call reported sleep hours (p = 0.036). There was no statistically significant difference between the Pre-call and Post-call groups or between the Fatigued and Nonfatigued groups in time to complete exercise, number of attempts, and high MScore™ score., Conclusion: Despite variation in fatigue levels, there was no effect on the acquisition of robotic simulator skills.

Background: The National Surgical Quality Improvement Program (NSQIP) began with the Veterans Affairs system to reduce morbidity and mortality by evaluating preoperative risk factors, postoperative occurrences, mortality reports, surgical site infections, and patient variable statistics. Our institution enrolled in NSQIP July 2006. The Surgical Care Improvement Project (SCIP) was developed to reduce surgical complications, including surgical infections. We began instituting SCIP protocols in July 2007., Study Design: This is a retrospective review of the NSQIP data collected by our NSQIP nurse. The colorectal surgical site infection (SSI) data pre- and post-institution of SCIP guidelines are analyzed. Data from the July 2006 to June 2007 and July 2007 to June 2008 reports are compared. Rates of SCIP compliance are analyzed., Results: There were 113 colorectal cases in the July 2006 to June 2007 NSQIP report. The rate of superficial SSI was 13.3%, with an expected rate of 9.7% (p = 0.041). The observed-to-expected ratio was 1.39. Compliance with SCIP was 38%. There were 84 colorectal cases in the July 2007 to June 2008 NSQIP report. The rate of superficial SSI was 8.3%, with an expected rate of 10.25% (p = 0.351). The observed-to-expected ratio was 0.81. Compliance with SCIP measures was 92%., Conclusions: Participation in NSQIP can identify areas of increased morbidity and mortality. Our institution was a high outlier in superficial SSI in colorectal patients during the first NSQIP evaluations. SCIP guidelines were instituted and a statistically significant reduction in our rates of SSI was realized. As our compliance with SCIP improved, our rates of superficial SSI decreased. Reduction in superficial SSI decreases cost to the patient and decreases length of stay., (Copyright 2010 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: In response to the Accreditation Council for Graduate Medical Education (ACGME) mandated 80-hour workweek, the night float coverage model was one system created to comply with the work-hour restriction. However, concern has risen as to the operative case volume achieved with this model. The purpose of this study is to determine which system of call (night float vs traditional rotating call) provided the senior surgical resident with the greatest surgical case volume while in compliance with the 80-hour workweek., Methods: A nonrandomized sequential study to evaluate the ACGME surgical operative logs (SOLs) for surgical chief residents at Memorial University Medical Center (MUMC), which is a level 1 trauma center, from 2006 to 2008 was conducted. The night float system (NFS) consisted of a PGY-4 or -5 assigned to in-house general surgery and trauma call from 6:00 pm to 6:00 am Monday through Friday morning and a 24-hour shift from 6:00 am on Sunday to 6:00 am Monday morning. Two months of night call rotations (nights) are performed each year per resident with the other 10 months devoted to daytime rotations (days). Conversely, the traditional rotating call schedule (TCS) placed each resident on-call every sixth night for a 30-hour period. The TCS required the resident to average approximately 3 weekday and 2 weekend calls per month. The data examined include all cases on the ACGME SOL submitted by each PGY-4 and 5 residents over a 2-year span. Specific designation of cases between night and day rotations was evaluated while on the NFS, and the total cases volume performed on the NFS and the TCS were analyzed., Results: An evaluation of the 2006-2007 (NFS) year demonstrates an average of 16 cases per month while on nights as compared with 20 cases per month while on day rotations. The caseload on the night rotation was less than day rotations at the PGY-4/5 level. An analysis of the 2006-2007 (NFS) and 2007-2008 (TCS) for PGY-4/5 residents revealed an average total caseload of 224 and 276, respectively. A statistically significant total case difference of 52 cases over the entire year between the 2 systems of call was appreciated., Conclusions: Because of the work-hour restrictions, maximizing surgical education has become a necessity. With the various call systems used throughout general surgery programs, this study specifically compares a traditional 1-in-6 call schedule versus an NFS. Senior residents lost significant operative experience while operating under an NFS as compared with a TCS. Evidence suggests that the more hours spent by a chief resident during normal operative time elicits more operative experience.

A 75 year-old woman presented to the authors' institution with abdominal pain and early satiety. An adrenal mass was found on CT scanning. Laparoscopic adrenalectomy was performed, and the patient was found to have a retroperitoneal bronchogenic cyst adherent to the adrenal gland. The workup of an adrenal mass is discussed as well as the pathophysiology of bronchogenic cysts.

Minimally invasive esophageal surgery has the potential to improve mortality, hospital stay, and functional outcomes when compared with open methods. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. A case series of 20 patients who underwent minimally invasive total esophagectomy is presented. This study was a review of a prospective database. The purpose was to evaluate early results with laparoscopic total esophagectomy for benign and malignant disease. Between January 2003 and November 2005, 20 patients underwent minimally invasive esophageal surgery. All operations were performed by the same two surgeons. Age, gender, indications for surgery, pathologic stage, operative time, blood loss, transfusion requirements, intensive care unit length of stay, hospital length of stay, postoperative complications, and mortality were recorded. Diet progression, dysphagia, and need for stricture management were also recorded. Of the 20 minimally invasive total esophagectomies performed, 18 (90%) were completed successfully. The average age of the patients was 53 years. Indications for surgery were malignancy (n = 13), carcinoma in situ in the setting of Barrett's esophagus (n = 2), and benign stricture (n = 3). The average operating time was 467 minutes (range 346-580 min). Median blood loss was 350 mL (range 150-500 mL). The median intensive care unit stay was 2 days, and the median hospital length of stay was 12 days. Pathology revealed that 7 per cent of patients had stage I disease, 27 per cent of patients had stage II disease, and 53 per cent of patients had stage III disease. There was a single mortality (5%), a cervical leak in two patients (10%), a gastric tip necrosis in one patient (5%), and tracheoesophageal fistula in one patient (5%). Major complications occurred in eight patients (40%) and minor complications in nine (50%). Thirteen (72%) patients were discharged on enteral tube feeds to supplement caloric intake. The application of minimally invasive techniques in the arena of esophageal surgery continues to evolve. This approach has the potential to improve mortality, hospital stay, and other outcomes when compared with open methods. Although technically complex, laparoscopic total esophagectomy is feasible.

Retrograde intussusception is exceedingly rare and has not been reported after a pancreaticojejunostomy. Recurrent retrograde intussusception has been reported only once before. In adults retrograde intussusception has been associated with gastric resection, gastrojejunostomy, Roux-en-Y gastric bypass, and gastrostomy tube placement. We report a case of retrograde intussusception of the efferent limb into the anastomosis of a revised Roux-en-Y bypass of the pancreas. Two long side-to-side anastomoses with plication were performed to prevent a third episode of intussusception involving this patient's Roux-en-Y.

A case is described of a clinically occult carotid artery lesion secondary to penetrating trauma. Angiography displayed a small intimal defect, whereas surgical exploration revealed significant intimal damage requiring excision and interposition grafting. This case supports the benefit of continued definitive operative management for carotid artery injuries.